Aortic valve surgery in the elderly patient: a retrospective review

Elderly patients are referred with increasing frequency for aortic valve replacement (AVR), due to the ageing of the population and to improved results of surgery. We retrospectively analysed the in-hospital and short-term (up to three years) results of AVR in 185 patients aged >or=75 years, operated on at our institution from January 2000 to December 2003. Follow-up was completed by a telephone interview during January 2005. Hospital mortality was 6.5% (12 patients). A non-elective operation (P=0.001), preoperative NYHA functional class >or=III (P=0.06), and chronic renal failure (P=0.02) were associated with increased operative mortality. Of note, age >or=80 years did not increase the surgical risk. The 4-year actuarial survival was 70.5%, the event-free survival was 60.6%, and almost all of the interviewed patients thought that they had benefited from the operation. Preoperative intubation, a NYHA class >or=III, and a non-elective operation were univariate predictors of a poorer outcome. Our data show that aortic valve replacement may be performed with low morbidity and mortality in the elderly patient (age >or=75 years), and that an age >or=80 years neither increases the surgical risk, nor significantly worsens the short-term outcome.     

Aortic valve replacement in an elderly patient with factor XI deficiency

Factor XI (FXI) deficiency is rare and associated with bleeding after surgical procedures. We report a case of an 80-year-old woman with severe aortic valve stenosis. FXI deficiency was diagnosed due to prolonged activated partial thromboplastin time. Aortic valve replacement was performed using a porcine bioprosthetic valve. Intra-operation bleeding was controlled by the transfusion of a fresh frozen plasma. The postoperative course was uneventful.     

Aortic valve replacement in elderly patients

The results for 62 consecutive patients aged 70 or more given aortic valve replacement (A.V.R.) between 1970 and 1982 are reported. All the patients were in the New York Heart Association (N.Y.H.A.) functional class III (29%) or IV (71%); 54.8% had angina and 30.6% had experienced syncope. Forty patients had aortic stenosis (A.S.), 10 had aortic regurgitation and 12 had mixed aortic valve disease. The operative myocardial infarction rate was 6.4%. Tilting disk valves were used. Eighty percent of the patients were anticoagulated with Warfarin whilst twenty percent received only antiplatelet drugs. All the patients were followed up for a mean period of 26 months; late mortality was 22.6% with 4.8% cardiac deaths. The thromboembolic rate was 1.6% and the disinsertion rate was 3.2%. Cerebral stroke was fatal in 3 cases in anticoagulated patients but the mechanism of the accident was not known. At the termination of the study 93% of surviving patients were in N.Y.H.A. class I or II. No patient was in class IV. The probability of five year survival is 71% for the entire group.     

Aortic valve replacement in the anephric patient.

A 30-year-old anephric patient on a home dialysis program developed bacterial endocarditis, aortic insufficiency, and severe hear failure. After a period of intensive medical management she underwent aortic valve replacement successfully. One year following operation she continues to do well and is again managed by home dialysis without further complication.     

Aortic valve papillary fibroelastoma in a patient with mitral valve regurgitation

Papillary fibroelastoma is a rare cardiac tumour. We describe a patient with mitral valve regurgitation and aortic valve papillary fibroelastoma. The patient was 62-year-old woman. She was referred to us for surgical treatment of mitral valve. Preoperative echocardiography showed rheumatic mitral valve regurgitation (Sellers grade III) and it also demonstrated mobile masses of the aortic valve. At operation, mitral valve was repaired by a posterior annuloplasty. Through the aortotomy, small tumors were found to be attached to each cusps of the aortic valve and they were successfully removed. The histopathologic diagnosis was papillary fibroelastoma of the aortic valve. The postoperative course was uneventful.     

Aortic valve replacement for the patient with Osler-Rendu-Weber disease

Osler Rendu-Weber (O-R W) disease (hereditary haemorrhagic telangiectasia) is characterized by an anormality of the peripheral blood vessels which often causes recurrent epistaxis. We presented a case of aortic valve replacement for the patient with O-R-W disease. A 75-year-old woman diagnosed as O-R-W disease with chest pain and dyspnea was admitted. Preoperative transthoratic echocardiography showed severe aortic valve stenosis (AS) with a pressure gradient (from left ventricle to ascending aorta) of 72.5 mmHg. Urgent aortic valve replacement (AVR) was performed after preoperative hormonal (estrogen-progesterone) therapy, that might be effective for bleeding from vascular ectasia. No hemorrhagic tendency was recognized and the postoperative course was uneventful.     

Aortic valve repair in a patient with congenital afibrinogenemia

We describe the management of cardiopulmonary bypass (CPB) in a patient with congenital afibrinogenemia (AF). Although this state is akin to the state after hirudin administration, where CPB has been successfully performed, heparinization is still essential to preserve other clotting factors and prevent excessive bleeding. Aprotinin further helps in preservation of clotting factors. There are case reports of thrombosis associated with AF, but aprotinin can be safely used because it is, by definition, an anticoagulant. Cryoprecipitate effectively restores the fibrinogen and produces normal clotting.     

Aortic valve replacement in a patient with erythropoietic protoporphyria

Erythropoietic protoporphyria (EPP) is a disorder of heme synthesis that causes excessive accumulation of protoporphyrin. The predominant clinical feature is photosensitivity triggered by light at wavelengths near 400 nm. We describe a 52-year-old man with EPP who underwent aortic valve replacement due to severe regurgitation. To prevent burn injuries, astral lamps in the operating room were covered with yellow film filters. Preoperative autologous blood donation was not undertaken. Blood priming of the extracorporeal circuit was performed to maintain adequate hemoglobin concentrations, which resulted in reduction of heme synthesis. The patient was discharged in good health without any signs or symptoms of EPP.     

Aortic biological valve thrombosis in an HIV positive patient

Biological aortic valve thrombosis is an exceptional complication. A 64-year-old patient positive for human immunodeficiency virus presented for syncope on exertion, 2 years after an aortic bioprosthetic valve replacement and double coronary artery bypass. Transvalvular aortic mean gradient was approximately 50 mm Hg on echocardiogram and catheterization. Cardiac computed tomography scan showed a limited opening of the bioprosthesis cusps. Surgical exploration revealed thrombosis of the three cusps on the aortic side, limiting the opening of the valve. No relation could be established between the patient's human immunodeficiency virus status and valve thrombosis.     

Aortic valve replacement in a patient with morquio syndrome

Cardiac involvement in Morquio syndrome, mucopolysaccharidosis IV, is characterized by aortic and mitral valve thickening and infiltration of the coronary arteries. There are few reports concerning surgical interventions in patients with mucopolysaccharidoses. We report a case of a patient affected by Morquio syndrome who underwent aortic valve replacement surgery for severe aortic valve stenosis, with an uneventful postoperative course. Cardiac surgery appears safe and feasible in these patients and improves the quality of life, even if the future prognosis related to the underlying disorder should be considered.     

Aortic valve replacement in a patient with thalassemia intermedia

We report a very rare case of mitral valve injury due to gunshot, presenting 1 year after the incident. The bullet had traversed through the chest and had gone through the anterior mitral leaflet to reside in the pericardium. The first clinical presentation was unremarkable and the patient became symptomatic 1 year later. We operated on him for severe mitral valve regurgitation, repairing the hole in the anterior mitral leaflet. The 1-year follow-up showed a good symptomatic and echocardiographic success.     

Aortic valve replacement with the composite Labcor porcine bioprosthesis in the elderly

BACKGROUND: This paper presents the analysis of clinical results of the composite porcine Labcor bioprosthesis in the replacement of aortic valves in the elderly. METHODS: This retrospective study was carried out in the Thoracic and Cardiovascular Surgical Department, La Pitié-Salpétrière Hospital, Paris, for replacement of calcified, stenosed aortic valves between 1988 and 1995. It involved a series of 100 patients aged 70 and over (mean: 80+/-5 years ranging from 70 to 90). There were 63 female and 37 male patients. Preoperatively, five patients were in NYHA Class I, 23 in Class II, 65 in Class III and 7 in Class IV. RESULTS: Fifteen patients died in the early postoperative stage and 13 during the follow-up period. There was no evidence of valve failure. The average follow-up was 32 months and the actuarial survival rate at 5 years was 74+/-5%. Complications due to bleeding occurred in 3 patients taking anticoagulant treatment. There were neither valvular thrombosis nor embolism. Two patients presented with prosthetic endocarditis. Two patients received a reoperation because of leakage (1 septic). The five-year follow-up showed that 96% of patients did not require further surgery. When this study was completed, 83% of patients were in Class I or II versus 71% in Class III or IV prior to surgery. CONCLUSIONS: In the early/middle follow-up term, the results obtained when replacing the aortic valve with the composite Labcor bioprosthesis in the elderly are satisfying. Nevertheless, further long-term assessment is needed.     

Aortic valve replacement in a patient with idiopathic thrombocytopenic purpura

A patient with aortic regurgitation and idiopathic thrombocytopenic purpura underwent a successful valve replacement. Cardiac surgery requiring a cardiopulmonary bypass in idiopathic thrombocytopenic purpura can be safely carried out with the preoperative intravenous administration of high-dose gammaglobulin, which may thereby reduce the need for either perioperative transfusion or prophylactic splenectomy.     

Aortic valve replacement in a patient with a brain tumor

We report a case of aortic stenosis with a brain tumor in a 67-year-old man. Although he showed no clinical neurological abnormality, a computed tomography scan revealed a brain tumor. We performed aortic valve replacement under several management techniques to avoid cerebral injury. Two biochemical markers for brain injury, S-100beta and neuron-specific enolase, were measured perioperatively. The postoperative course was uneventful without neurological complication, and the biochemical markers were within the control ranges.