In-hospital outcome in octogenarians with acute coronary syndrome undergoing emergent coronary angiography

Very elderly patients have higher mortality rates than younger patients after acute coronary syndrome (ACS). However, the mechanism by which increasing age contributes to such mortality remains unclear. In addition, the efficacy and safety of invasive coronary procedures for octogenarians with ACS have not been well established. We compared the clinical characteristics and in-hospital outcome of 193 octogenarians (mean age, 83 years) with those of 1,462 younger patients (mean age, 64 years) with ACS who underwent emergent coronary angiography. Octogenarians included a greater number of females, had higher rates of cerebrovascular disease and multivessel disease, a higher Killip class, a higher Forrester class, and lower rates of smoking, diabetes, and hypercholesterolemia than the younger subjects. Interventions, including percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG), were performed less frequently in octogenarians than in younger patients (88.0% versus 90.8%). The procedural success rate in octogenarians did not differ from that in younger patients. However, the in-hospital mortality rate for the octogenarians was about three times higher than for the younger patients (19.2% versus 6.9%). Multivariate analysis revealed that the predictors of in-hospital mortality in the octogenarians were a higher Killip class and a higher Forrester class. Octogenarians with ACS had fewer coronary risk factors and a similar success rate for the intervention, but had more greatly impaired hemodynamics and higher in-hospital mortality than the younger patients. Therefore, impaired myocardial reserve may contribute to a large portion of in-hospital deaths in octogenarians with ACS.     

The Hidden Risks of Advancing Age and Concomitant Ischemic Heart Disease After Aortic Valve Replacement

Background:

Despite an increasing patient risk profile, in‐hospital mortality after aortic valve replacement (AVR) has declined.

Hypothesis:

Advanced age, concomitant coronary artery bypass grafting (CABG), and increasing comorbidity negatively affect outcomes after AVR and do so particularly in the early months after hospital discharge, where results compare much less favorably with mortality during the first 30 days.

Methods:

The study population consisted of all patients undergoing elective AVR by a single surgeon, with and without CABG, in the decade of 2000–2009. Age, logistic EuroSCORE, diabetes, type of operation, and 30‐day and 1‐year mortality were recorded.

Results:

One hundred ninety‐one patients underwent isolated AVR; 133 underwent AVR + CABG. The average age increased by 5.7 years, octogenarians by 50%, logistic EuroSCORE by 18%, and the proportion of diabetics from 4% to 25.5%. Concomitant CABG surgery increased from 36% to 49%. Overall mortality for isolated AVR was zero in the first 30 days and 1.6% in the next 11 months. For AVR and CABG, mortality was 3.75% and 9%, respectively. For octogenarians, mortality was zero and 5.9% for AVR and 4.76% and 14.29% for AVR and CABG at 30 days and in the next 11 months, respectively.

Conclusions:

Thirty‐day mortality in all age groups remained low but was much higher in the short term after discharge from hospital, particularly in octogenarians and those with concomitant ischemic heart disease. This should inform the consent process (which traditionally concentrates on in‐hospital mortality) and there should be greater awareness of the frailty and particular requirements of the elderly after discharge. This work was presented at the meeting of the Scandinavian Society for Research in Cardiothoracic Surgery, Geilo, Norway, February 10, 2012. The authors have no funding, financial relationships, or conflicts of interest to disclose.     

Outcomes after aortic and mitral valve replacement surgery in Canada: 1994/95 to 1999/2000

BACKGROUND: Although outcomes after coronary artery bypass grafting (CABG) have been studied extensively across Canada, using both clinical and administrative databases, studies examining outcomes after valve surgery in Canada have been restricted to regional investigations using clinical data sources of limited scope. The objective of the present study was to report on observed and risk-adjusted in-hospital mortality rates after aortic valve replacement (AVR) and mitral valve replacement (MVR) across Canada between 1994/95 and 1999/2000 using administrative data. METHODS: All cases of AVR and MVR (with and without concomitant CABG) performed between 1994/95 and 1999/2000 were identified using hospital discharge abstract data obtained from the Canadian Institute for Health Information. Rates of in-hospital mortality were risk-adjusted using logistic regression modelling techniques to account for variations in sociodemographic, comorbidity, and disease-specific indicators of average severity of illness across years and provinces. Risk-adjusted outcomes were unavailable for the province of Quebec. RESULTS: The overall in-hospital mortality rate, excluding Quebec, between 1994/95 and 1999/2000 after isolated AVR with or without CABG was 3.7% and isolated MVR with or without CABG was 5.7%. Although risk-adjusted in-hospital mortality rates by year were unchanged between 1994/95 and 1999/2000, significant interprovincial variation did exist, ranging from 2.6% to 6.8% for AVR with or without CABG and 2.5% to 13.0% for MVR with or without CABG. CONCLUSION: In-hospital mortality rates after valve surgery have remained stable over time. However, significant variation in outcomes was noted between provinces. The results of this study provide the first comprehensive account of valve surgery outcomes across Canada.     

Cardiac surgery in octogenarians; peri-operative outcome and long-term results.

AIMS: Because the elderly are increasingly referred for operation, we reviewed the results of cardiac surgery in patients of 80 years or older. METHODS AND RESULTS: Records of 182 consecutive octogenarians who had had cardiac operations between 1992 and 1998 were reviewed. Follow-up was 100% complete. Seventy patients had coronary grafting (CABG), 70 aortic valve replacement, 30 aortic valve replacement+CABG, and 12 mitral valve repair/replacement. Rates of hospital death, stroke, and prolonged stay (>14 days) were as follows: CABG: 7 (10%), 2 (2.8%) and 41 (58%); aortic valve replacement: 6 (8.5%), 2 (2.8%) and 32 (45.7%); aortic valve replacement+CABG: 8 (26.5%), 1 (3.8%) and 14 (46.6%); mitral valve repair/replacement: 3 (25%), 1 (8.3%) and 5 (41.6%). Multivariate predictors (P<0.05) of hospital death were New York Heart Association functional class, urgent procedure, prolonged cardiopulmonary bypass time, and, after aortic valve replacement, previous percutaneous aortic valvuloplasty. Ascending aortic atheromatous disease was predictive of stroke, while pre-operative myocardial infarction was predictive of prolonged hospital stay. Actuarial 5-year survival was as follows: CABG, 65.8+/-8.8%; aortic valve replacement, 63.6+/-7.1%; aortic valve replacement+CABG, 62.4+/-6.8%; mitral valve repair/replacement, 57.1+/-5.6%; and total, 63.0+/-5.6%. Multivariate predictors of late death were pre-operative myocardial infarction, and urgent procedure. Ninety percent of long-term survivors were in New York Heart Association class I or II, and 87% believed having a heart operation after age 80 years was a good choice. CONCLUSION: Cardiac operations are successful in most octogenarians with increased hospital mortality, and longer hospital stay. Long-term survival and quality of life are good.     

Prediction of operative mortality after valve replacement surgery.

OBJECTIVES: We sought to develop national benchmarks for valve replacement surgery by developing statistical risk models of operative mortality. BACKGROUND: National risk models for coronary artery bypass graft surgery (CABG) have gained widespread acceptance, but there are no similar models for valve replacement surgery. METHODS: The Society of Thoracic Surgeons National Cardiac Surgery Database was used to identify risk factors associated with valve surgery from 1994 through 1997. The population was drawn from 49,073 patients undergoing isolated aortic valve replacement (AVR) or mitral valve replacement (MVR) and from 43,463 patients undergoing CABG combined with AVR or MVR. Two multivariable risk models were developed: one for isolated AVR or MVR and one for CABG plus AVR or CABG plus MVR. RESULTS: Operative mortality rates for AVR, MVR, combined CABG/AVR and combined CABG/ MVR were 4.00%, 6.04%, 6.80% and 13.29%, respectively. The strongest independent risk factors were emergency/salvage procedures, recent infarction, reoperations and renal failure. The c-indexes were 0.77 and 0.74 for the isolated valve replacement and combined CABG/valve replacement models, respectively. These models retained their predictive accuracy when applied to a prospective patient population undergoing operation from 1998 to 1999. The Hosmer-Lemeshow goodness-of-fit statistic was 10.6 (p = 0.225) for the isolated valve replacement model and 12.2 (p = 0.141) for the CABG/valve replacement model. CONCLUSIONS: Statistical models have been developed to accurately predict operative mortality after valve replacement surgery. These models can be used to enhance quality by providing a national benchmark for valve replacement surgery.     

Determinants of survival after aortic valve replacement as treatment for symptomatic aortic valve disease in the elderly

BACKGROUND AND AIM OF THE STUDY: The effect of concurrent disease and cardiac comorbidity on survival after bioprosthetic valve replacement in elderly patients was assessed retrospectively. Risk factors were categorized as general, non-cardiac (age, diabetes, previously treated carcinoma) and cardiac (LVEF, three-vessel disease, previous CABG or valve replacement, and endocarditis). METHODS: A total of 400 elderly patients (median age 73 years; range: 71-76 years) was studied. Medical history included diabetes, previous CABG or aortic valve replacement (AVR), endocarditis and treatment of previous carcinoma. A left ventricular ejection fraction (LVEF) of <0.66 and presence of three-vessel disease were also investigated. Hospital deaths (and cause) were recorded; survival or date and cause of death after discharge were obtained by questionnaire. Kaplan-Meier univariate and Cox proportional hazards multivariate regression analyses were carried out. RESULTS: Mortality during follow up was 28.3%; hospital mortality was 3.8%. Univariate analysis showed five factors significantly to affect survival: LVEF, history of endocarditis, carcinoma, age and three-vessel disease. Fifteen of 38 patients with history of carcinoma died, 10 due to a malignancy. Of 76 patients with three-vessel disease, 26 died. A history of diabetes and previous CABG did not influence survival significantly. Four of eight patients with preoperative endocarditis died, all in hospital. Six of 11 patients died after redo-AVR, none before 36 months follow up. By Cox regression analysis, LVEF and histories of carcinoma and endocarditis remained significant. CONCLUSION: AVR should be performed before ventricular deterioration occurs. Previous CABG is not a contraindication for AVR. Endocarditis impaired survival. Long-term mortality after redo-AVR in this population was relatively high, but acceptable. AVR should also be performed in elderly patients with aortic valve disease. Since prognosis of symptomatic aortic valve disease is poor in the short term, AVR is indicated in patients treated for carcinoma.     

Coronary artery bypass surgery in octogenarians: outcomes in a tertiary referral university hospital in a developing country

BACKGROUND: The number of people older than 80 years is increasing worldwide and many of these patients are being referred for coronary artery bypass surgery (CABG). Several recent reports from the USA and Europe have shown that CABG can be performed in octogenarians with an acceptable risk. However, data from developing countries regarding this subject is lacking. The objective of this study was to analyze the clinical characteristics and in-hospital events of octogenarian patients undergoing CABG at a tertiary referral university hospital in a developing country. METHODS: The study included 28 consecutive octogenarian patients who underwent CABG at the American University of Beirut, between January 1998 and December 2000. The medical records of these patients were reviewed for demographic information, clinical and catheterization findings, operative characteristics, and in-hospital events (death, myocardial infarction, and stroke). RESULTS: The mean age of the study group was 82 +/- 2 years and 75% were males. Seventy-eight percent of the patients had an acute myocardial infarction or unstable angina prior to CABG. All of the patients were in NYHA class I or II and none of the operations were done on an emergent basis. The mean ejection fraction was 48 +/- 7%. Eighty-six percent of patients had multivessel disease and four patients had aortic valve replacement (AVR) concomitantly with the CABG. The in-hospital mortality was 0%. Three patients (11%) had a post-operative myocardial infarction, and one patient (4%) had a stroke. The mean post-operative stay was 9 +/- 7 days with only three patients (11%) staying for more than 14 days. The multivariate predictors of in-hospital cardiovascular events were concomitant AVR (P=0.01), and an ejection fraction <40% (P=0.03). CONCLUSION: In carefully selected octogenarian patients who are clinically stable in NYHA class I or II, and where the operation is not done on an emergent basis, CABG can be performed with an acceptable risk and a low in-hospital mortality.     

Outcome and risk factors in octogenarians undergoing open-heart surgery

BACKGROUND AND AIM OF THE STUDY: Increasing numbers of elderly (aged > 80 years) patients are being referred for cardiac surgery, and results for coronary artery bypass grafting (CABG) are generally better than for combined CABG and valve replacement. METHODS: During the past 55 months, 77 octogenarians underwent cardiac intervention in our institution. Forty-five patients (mean age 82.5 years) underwent CABG alone; surgery was elective in 33% of patients and 2.7 +/- 1.0 grafts per patient were performed. Thirty-two patients (mean age 82.4 years) underwent combined CABG and valve surgery (28 aortic, four mitral); 2.1 +/- 0.8 grafts per patient were performed and 65% of cases were emergencies. RESULTS: In patients undergoing CABG alone, the operative mortality rate was 2% and rose to 4% (n = 2) at the end of follow up. Mean NYHA functional class improved significantly from 3.5 +/- 0.5 to 1.4 +/- 0.3 after surgery (p < 0.05) and most patients reported marked improvement in their quality of life. In CABG + valve surgery patients, the operative mortality rate was 6% (n = 2) and reached 18% by the end of follow up. In these patients the complication rate was 24% and mean hospitalization stay 11.0 +/- 2.9 days, while mean NYHA functional class improved from 3.4 +/- 0.6 to 1.2 +/- 0.5. Data analysis revealed that mitral regurgitation combined with coronary artery disease (p < 0.03) and prolonged cross-clamping time (p < 0.01) were the most important independent factors for mortality. CONCLUSION: This study confirms that, in selected elderly patients, combined CABG and cardiac surgery can achieve good postoperative results.     

Heart surgery in the elderly

Heart surgery has been performed in an increasing number of elderly patients in the recent years. Currently about 20 % of all patients in cardiac surgery are older than 75 years, however their number is increasing constantly. Valve replacement (mainly aortic valve replacement, AVR), coronary artery bypass grafting (CABG) or combined procedures (AVR and CABG) are the most common procedures in the elderly. However, surgical therapy of heart failure, implantation of assist devices or cardiac transplantation have been performed only in a limited number of elderly patients. Surgical pathways in the therapy of coronary artery disease or valve disease are described. Furthermore, age related morbidity and mortality and related surgical options to improve the outcome are discussed.     

Cardiac surgery in patients on chronic hemodialysis: short and long-term survival

OBJECTIVE: Open-heart surgery carries a high risk for hemodialysis patients. This study focuses on the short and long-term outcomes of hemodialysis patients undergoing heart surgery. DESIGN: The study was carried out as a retrospective analysis in the Department of Cardiothoracic Surgery in a large university-affiliated hospital. PATIENTS: 115 hemodialysis patients underwent cardiac surgery in our department between 1 July 1996 and 31 July 2006. 67.5 % (77 patients) underwent isolated coronary artery bypass grafting (CABG), 13.2 % (15 patients) underwent isolated aortic valve replacement (AVR) and 20.2 % (23 patients) underwent mitral valve surgery or combined valve and coronary artery bypass grafting or multiple valve surgery. METHODS: The relationship between several variables (age, sex, hypertension, diabetes, and previous myocardial infarction, type of disease, preoperative ejection fraction, and congestive heart failure) and operative (30 days) mortality and late survival was analyzed. RESULTS: The overall 30-day mortality was 18.3 % (21 patients). It was 13 % (10/77 patients) for the isolated CABG group and 13.3 % (2/15) for the isolated AVR group. Patients undergoing combined valve and coronary surgery or multiple valve surgery had a higher perioperative mortality of 39.1 % (9/23) compared to the isolated CABG and isolated AVR patients. Perioperative death was also higher in patients with moderate and severe LV dysfunction, and in patients with diabetes. The duration of dialysis periods was not related to perioperative death. Mean follow-up was 26.4 +/- 29.7 months (0.1 to 104 months). Actuarial survival at 1 year and 5 years was 76 % and 55 % for isolated CABG, 59 % and 21 % for isolated AVR, and 44 % and 33 % for all other cases, respectively (log rank P = 0.001). CONCLUSION: Patients on dialysis have a high risk of perioperative mortality and poor long-term survival rates. Mortality is higher and survival is worse after combined CABG and valve-related procedures or multiple valve surgery than after isolated CABG and AVR.     

Cardiac surgery for octogenarians--a suitable procedure? Twelve-year operative and post-hospital mortality in 641 patients over 80 years of age

OBJECTIVES: The increase in life expectancy as a result of therapeutic improvements subsequently leads to a large number of patients with advanced age. The aim of this study was to review the 30-day mortality and mid-term outcome of octogenarians undergoing coronary artery bypass grafting (CABG) or valve replacement (AVR/MVR). METHODS: The data of 641 patients with a mean age of 82.6 years (range 80.0 - 92.6), operated between 9/93 and 12/05, were reviewed. 432 patients underwent CABG, 188 had AVR and 21 had MVR. We analysed peri-/postoperative mortality and clinical outcomes. Follow-up was obtained by phone contact with patients or their physician. Mid-term survival was determined for the whole population by the Kaplan-Meier method; peri- and postoperative risk factor analysis was done using logistic regression. Follow-up ranged from 0.1 to 11.8 years (mean 3.6 +/- 2.6) and was complete for 99%. RESULTS: We observed a perioperative mortality of 8.8% for CABG, 4.8% for AVR and 9.5% for MVR. Perioperative mortality was strongly associated with urgent/emergent operations (P < 0.03), poorer clinical status (P < 0.03), renal dysfunction (P < 0.05) and male gender (P < 0.04). Actuarial survival after 3, 5 and 8 years was as follows: CABG 78%, 66% and 44%; AVR 79%, 68% and 38%; MVR 76%, 61% and 23%. The mean NYHA functional class for survivors improved in the group of patients with CABG from 2.7 to 2.0 (P < 0.03), in the AVR group from 2.8 to 2.0 (P < 0.03), and in the MVR group from 2.9 to 2.3 (P < 0.05). More than 80% of all surviving patients live at home, either alone or with their family. CONCLUSION: In our cohort of octogenarians, cardiac surgery was found to be associated with an acceptable, although increased perioperative mortality. Despite the enhanced perioperative risk, the clinical benefit, as verified by improved functional status and satisfactory mid-term survival rates, justifies surgery in these patients with advanced age.     

Valve structure and survival in octogenarians having aortic valve replacement for aortic stenosis (+/- aortic regurgitation) with versus without coronary artery bypass grafting at a single US medical center (1993 to 2005)

The purpose of this study was to determine the effect of simultaneous coronary artery bypass grafting (CABG) and valve structure on both early and late survival in octogenarians having aortic valve replacement (AVR) for aortic stenosis (AS) (with or without aortic regurgitation). Although a number of reports are available in octogenarians having AVR for AS, none have described aortic valve structure. Most have limited numbers of patients and few have described late results. We analyzed survival and valve structure in 196 octogenarians having AVR for AS from 1993 to 2005 at Baylor University Medical Center, including 118 (60%) with and 78 (40%) without simultaneous CABG. Sixty-day mortality, which was identical to 30-day mortality, was similar (10% and 11%) in the groups with and without simultaneous CABG. Unadjusted analysis of late survival (up to 13 year follow-up) was not affected by gender (male vs female), aortic valve structure (bicuspid vs tricuspid) or preoperative severity of the AS (transvalvular peak pressure gradient > 50 vs < or =50 mm Hg), or by performance of CABG. Of the 196 patients, 54 (28%) had a congenitally bicuspid aortic valve, and 142 (72%) had a tricuspid aortic valve. In conclusion, gender, valve structure, preoperative severity of the AS, or performance of simultaneous CABG did not effect survival in octogenarians having AVR for AS.     

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.     

One-hundred aortic valve replacements in octogenarians: outcomes and risk factors for early mortality

BACKGROUND AND AIM OF THE STUDY: Today, ageing of the western population is causing aortic valve surgery to be performed in elderly patients with increasing frequency. The study aim was to evaluate surgical outcome in octogenarian patients undergoing aortic valve replacement (AVR). METHODS: A total of 100 patients (mean age 82.1 +/- 2.7 years; range: 80-95 years) who underwent AVR over a three-year period was reviewed. Concomitant coronary artery bypass grafting was performed in 34% of cases, and a bioprosthesis was implanted in 80%. The mean logistic EuroSCORE was 13.3%. RESULTS: Operative mortality was 8.0%. In multivariate analysis, a logistic EuroSCORE > or =13.5% (p = 0.02), cross-clamp time > or =75 min (p = 0.02) and postoperative acute renal failure were predictors for in-hospital mortality. Follow up was 100% complete; the mean follow up period was 10.6 months. At one year after surgery, the actuarial survival rate of those patients who survived surgery was 86.1%. Postoperative dyspnea at one month (p = 0.004) was the only predictor of short-term mortality. CONCLUSION: Age in itself should not contraindicate surgery, and healthcare systems should be prepared to accommodate elderly patients who may require special resources.     

Valve surgery in octogenarians: a safe option with good medium-term results

BACKGROUND AND AIM OF THE STUDY: The number of octogenarians is increasing in industrialized societies, and many patients aged over 80 years have heart valve disease which is amenable to surgical treatment. The perioperative outcomes and long-term results in very elderly patients undergoing valve surgery were evaluated. METHODS: A retrospective analysis was conducted of 2,791 patients with long-term follow up, who underwent valve surgery between 1990 and 2002. Of these patients, 132 (68 males, 64 females) were aged over 80 years (mean age 82 +/- 2 years; range: 80-94 years). RESULTS: Ninety-five patients (71.9%) underwent aortic valve replacement, 36 (27.3%) mitral surgery, and one patient had double-valve surgery. Sixty-five patients (49.2%) required concomitant coronary artery bypass grafting. There were 11 (8.3%) redo procedures. Patients aged over 80 years were significantly more symptomatic preoperatively than their younger counterparts (NYHA class III-IV 90.9% versus 69.0%, p < 0.001), with more congestive cardiac failure, hypertension, peripheral vascular disease, obstructive pulmonary disease, and renal failure (all p < 0.05). Perioperative mortality did not, however, differ significantly between groups (< 80 years versus > or = 80 years, 2.9% versus 4.6%, p = 0.10). There was also no difference in the composite end point of in-hospital death, renal failure, stroke, low output state, myocardial infarction, or sternal wound infection (< 80 years versus > or = 80 years, 10.5% versus 11.4%, p = 0.8). The mean follow up period was 66 +/- 44 months (< 80 years) versus 61 +/- 37 (> or = 80 years). Late mortality was higher in the elderly group (10-year survival 37.9% versus 68.2%, p < 0.001) and preoperative atrial fibrillation (RR 2.75; CI: 1.44-5.23), coronary artery disease (RR 1.98; CI 1.12-3.52) and congestive cardiac failure (RR 2.13; CI: 1.10-4.11) were independent predictors of late mortality. The groups did not differ with respect to long-term valve-related events, with the exception of fewer reoperations among elderly patients. CONCLUSION: Valve surgery in selected octogenarians is associated with low morbidity and mortality. The outlook after surgery is very good, and surgery should not be denied to this group on the basis of age alone.     

The risk of reoperative heart valve procedures in Octogenarian patients

BACKGROUND AND AIM OF THE STUDY: The authors' experience is reported of cardiac reoperations for valvular heart disease in octogenarian patients. METHODS: The records of 22 consecutive patients (10 men, 12 women) aged > or =80 years (mean age 82.4+/-2.3 years) who underwent cardiac reoperation for aortic and/or mitral valvular heart disease at the authors' institution between 1991 and 2001 were retrospectively reviewed. RESULTS: Indications for reoperation were structural dysfunction of a previously implanted bioprosthetic valve in 11 patients (50%), new valvular heart disease in six (27%), progression of rheumatic valvular heart disease in four (18%), and prosthetic valve infective endocarditis in one patient (5%). Fourteen patients (64%) underwent isolated aortic valve replacement (AVR), two (9%) had AVR plus coronary artery bypass grafting (CABG), one patient (5%) had aortic root replacement plus CABG, three patients (14%) had isolated mitral valve replacement (MVR), one patient (5%) had MVR plus ascending aorta replacement, and one (5%) had AVR plus MVR. Postoperative complications occurred in 18 patients (82%). The hospital mortality rate was 32%. Actuarial survival estimates at one year, and at three and five years were 62.6%, 56.3% and 40.2%, respectively. CONCLUSION: Cardiac reoperations for valvular heart disease in octogenarians carry a high postoperative morbidity and mortality. These findings must be taken into account in the management of associated mild or moderate valvular heart disease, and in the choice of heart valve prosthesis at the initial operation in younger patients.     

性别和年龄对中国人冠状动脉旁路移植术后住院病死率的影响

目的确定中国人冠状动脉旁路移植术后住院病死率是否存在性别差异以及该差异是否与年龄相关.方法回顾性分析1997年1月1日至2001年12月31日阜外心血管病医院外科全部接受冠状动脉旁路移植术的患者共2682例（男性2316例,女性366例）.按照性别和年龄分组调查它们之间的围手术期并发症及手术后住院病死率的差异.结果女性术前合并主要疾病的比例比男性高,术后并发症多,但她们术前的左心室射血分数较男性好,且冠状动脉病变数量少.然而,女性患者的术后住院病死率是男性的3倍（女性3.01%,男性1.12%,P=0.001）,病死率的性别差异在低龄组更有统计学意义（女性2.6%,男性0.5%,P=0.001,ORs：4.844,95%可信区间：1.549～15.142）,在老年患者中则无统计学意义（女性3.7%,男性2.4%,P=0.383）.结论中国女性冠状动脉旁路移植术的住院病死率高于男性,特别是低龄女性.低龄组女性是住院病死率的独立危险因素.死亡率的性别差异随年龄增加而减少.需要进一步的研究来阐明病死率的性别差异在低龄组更显著的原因.     

Infective endocarditis in octogenarian patients

Our aims were to investigate the clinical features and prognosis of endocarditis in octogenarian patients (aged >79 years) and in comparison with those in younger elderly patients (aged 65-79 years) and young patients (aged <65 years). Octogenarian subjects more frequently were male and had a community-acquired infection, mitral valve disease, and chronic anemia. Their clinical course was more insidious and benign: they presented less often with fever or new heart murmurs. When heart failure was present, it tended to be less severe. The most frequently isolated microorganisms were streptococci. The detection rate for vegetation on transesophageal echocardiography was lower in octogenarians. Octogenarians had shorter periods of hospitalization, needed surgery less frequently, and had lower mortality. Mortality in those undergoing surgery was not higher in elderly patients. Age was not an independent predictor of in-hospital mortality.Full English text available from: www.revespcardiol.org     

Degeneration biologischer Aortenklappenprothesen im Senium

BACKGROUND: Due to increasing life expectancy of patients with heart valve replacement and a limited durability of heart valve bioprostheses, replacement of aortic valve prosthesis becomes necessary in a significant percentage of patients. However, reliable data on mortality and its risk factors in octogenarians after replacement of aortic bioprostheses are limited. PATIENTS AND METHODS: 56 patients aged > or = 80 years who underwent cardiac reoperation of a bioprosthesis due to structural valve deterioration at the authors' heart center between 1991 and 2004 were analyzed retrospectively. To assess predictors of 30-day and 3-year survival, uni- and multivariate Cox regression analyses were performed. RESULTS: 30-day, 1-year, 3-year, and 5-year survival rates were 81.1%, 71.3%, 67.5%, and 50.8%, respectively. Patients with reoperation had an estimated median survival of 5.0 years. Patients who survived their in-hospital stay had a very similar life expectancy compared with the general German population. Postoperative complications such as low cardiac output syndrome and intestinal failure were the only independent predictors of 30-day and 3-year survival (p < 0.001). Postoperative New York Heart Association functional class improved markedly in the study cohort and the majority of survivors was able to live at home. As we cannot offer these patients an alternative effective medical therapy, octogenarians who need their aortic valve prosthesis to be replaced are left in a miserable condition with a poor prognosis, if surgery is denied. Therefore, considering that almost the same criteria are used for younger patients with the emphasis that surgery should not be delayed until they are highly symptomatic, reoperation of the aortic valve in this age group is justified. CONCLUSION: The data demonstrate that it is possible to achieve an acceptable outcome in octogenarians who are in need of a replacement of their aortic valve prosthesis. Early as well as mid-term survival are predominantly influenced by unexpected postoperative complications.     

Are initial valve operations in octogenarians still high-risk in the current era?

BACKGROUND AND AIM OF THE STUDY: The average age of cardiac patients continues to increase. As more octogenarians undergo surgery during the current era, the outcome of valve surgery was investigated to determine the operative risk in these patients. METHODS: Among 350 patients aged > or = 80 years who had initial surgery between 1998 and 2006, a total of 188 (105 females, 83 males) underwent valve surgery. A prospective analysis was conducted of the collected data. RESULTS: The median age of patients was 82 years (IQR: 81-84 years), and over half of them presented with severe symptoms (NYHA class III/IV; n = 96), controlled heart failure (n = 108), hypertension (n = 101) and coronary artery disease (n = 108). Concomitant coronary artery bypass grafting (CABG) was performed in 89 cases (47%). Perioperative hemodynamic support with inotropes was common (47%). Hospital death after isolated aortic valve replacement (AVR) (n = 89) and mitral valve replacement (MVR) (n = 10) occurred in four patients (4.5%, median additive EuroSCORE 9.0%) and one patient (10%, median additive EuroSCORE 9.8%), respectively. Concomitant CABG led to a doubling of the operative mortality which, for AVR, declined from 5.4% to 3.8% during the latter half of the study period. The median length of stay was 24 h (IQR 21-44 h) in the intensive care unit, and 10 days (IQR 7-14 days) postoperatively. The risk factors for operative mortality were urgent/emergent surgery (HR 3.27, 95% CI 1.12-9.58, p = 0.03), preoperative gastrointestinal disease (HR 3.15, 95% CI 1.12-8.9, p = 0.03), left ventricular ejection fraction <0.30 (HR 4.37, 95% CI 1.29-14.82, p = 0.02), and ischemic time (HR 1.04, 95% CI 1.004-1.07, p = 0.02). CONCLUSION: Elective isolated AVR can be performed with modest operative risk in octogenarians with good left ventricular systolic function. Additional procedures impose long ischemic times and increase the operative risk, as does MVR. Strategies to minimize the complexity and extent of surgery should benefit these patients.