Aortic valve replacement in patients 70 years and older

New technique of local ischemic preconditioning induction without repetitive aortic cross-clamping in cardiac surgery

Background

Several studies have demonstrated that local ischemic preconditioning can reduce myocardial ischemia–reperfusion injury in cardiac surgery patients; however, preconditioning has not become a standard cardioprotective intervention, primarily because of the increased risk of atheroembolism during repetitive aortic cross-clamping. In the present study, we aimed to describe and validate a novel technique of preconditioning induction.

Methods

Patients undergoing coronary artery bypass grafting (12 women and 78 men; mean age, 56 ± 11 years) were randomized into 3 groups: (1) Controls (n = 30), (2) Perfusion (n = 30), and (3) Preconditioning (n = 30). All patients were operated under cardiopulmonary bypass using normothermic blood cardioplegia. Preconditioning was induced by subjecting the hemodynamically unloaded heart to 2 cycles of 3 min of ischemia and 3 min of reperfusion with normokalemic blood prior to cardioplegia. In the Perfusion group, the heart perfusion remained unaffected for 12 min. Troponin I (TnI) levels were analyzed before surgery, and 12, 24, 48 h, and 7 days after surgery. The secondary endpoints included the cardiac index, plasma natriuretic peptide level, and postoperative use of inotropes.

Results

Preconditioning resulted in a significant reduction in the TnI level on the 7th postoperative day only (0.10 ± 0.05 and 0.33 ± 0.88 ng/ml in Preconditioning and Perfusion groups, respectively, P < 0.05). In addition, cardiac index was significantly higher in the Preconditioning group than in the Control and Perfusion groups just after weaning from cardiopulmonary bypass. The number of patients requiring inotropic support with ≥ 2 agents after surgery was significantly lower in the Preconditioning and Perfusion group than in the Control group (P < 0.05). No complications of the procedure were recorded in the Preconditioning group.

Conclusions

The preconditioning procedure described can be performed safely in cardiac surgery patients. The application of this technique of preconditioning was associated with certain benefits, including improved left ventricular function after weaning from cardiopulmonary bypass and a reduced need for inotropic support. However, the infarct-limiting effect of preconditioning in the early postoperative period was not evident. The procedure does not involve repetitive aortic cross-clamping, thus avoiding possible embolic complications.

A systematic review on the quality of life benefits after aortic valve replacement in the elderly

BACKGROUND

Surgical aortic valve replacement is being increasingly performed in elderly patients with good perioperative outcomes and long-term survival. Evidence is limited on health-related quality of life after aortic valve replacement, which is an important measure of operative success in the elderly.

METHODS

A systematic review of clinical studies after January 2000 was performed to identify health-related quality of life in the elderly after aortic valve replacement. Strict inclusion and exclusion criteria were applied. Quality appraisal of each study also was performed using predefined criteria. Health-related quality of life results were synthesized through a narrative review with full tabulation of the results of all included studies.

RESULTS

Health-related quality of life improvements were shown across most or all domains in different health-related quality of life instruments. Elderly patients experienced marked symptomatic improvement. Health-related quality of life was equivalent or superior to both an age-matched population and younger patients undergoing identical procedures. There were excellent functional gains after surgery, but elderly patients remain susceptible to geriatric issues and mood problems. Concomitant coronary artery bypass did not affect health-related quality of life. There was a diverse range of study designs, methods, and follow-up times that limited direct comparison between studies.

CONCLUSIONS

Aortic valve replacement results in significant health-related quality of life benefits across a broad range of health domains in elderly patients. Age alone should not be a precluding factor for surgery. Data are heterogeneous and mostly retrospective. We recommend future studies based on consistent guidelines provided in this systematic review.

Aortic valve replacement in octogenarians: utility of risk stratification with EuroSCORE

BACKGROUND

With the advent of percutaneous valve implantation, an increasing amount of interest is being expressed in outcomes of conventional aortic valve replacement (AVR) in elderly patients. We evaluated characteristics and outcomes of elderly patients undergoing isolated AVR with a particular focus on the European System for Cardiac Operative Risk Evaluation (EuroSCORE) risk stratification.

METHODS

All patients aged 80 years or older (n = 282) undergoing isolated AVR between November 1995 and June 2006 at our institution were reviewed according to logistic EuroSCORE (ES(log)) risk stratification. Surgical risk was defined as low risk (ES(log) < or = 10% [n = 107]), moderate risk (10% < ES(log) < 20% [n = 103]), and high risk (ES(log) > or = 20% [n = 72]). Patient age was 82 +/- 2 years (low risk), 82.7 +/- 2.7 years (moderate risk), and 83.6 +/- 3.1 years (high risk), respectively (p < 0.05). Mean ES(log) predicted risk of mortality was 7.3% +/- 1.4% (low risk), 13.7% +/- 2.5% (moderate risk), and 33.0% +/- 11.5% (high risk; p < 0.05). Follow-up was 99.7% complete.

RESULTS

In-hospital mortality was 7.5% (low risk), 12.6% (moderate risk), and 12.5% (high risk; p = 0.4). One-year survival was 90%, 78%, and 69% (p = 0.002); 5-year survival was 70%, 53%, and 38% (p = 0.05); and 8-year survival was 38%, 33%, and 21% (p = 0.017), for low-, moderate-, and high-risk patients, respectively. Independent predictors for in-hospital mortality were pulmonary hypertension and urgent indication for surgery. Cox regression predictors of medium-term survival were congestive heart failure, urgent timing, previous stroke or transient ischemic attack, and EuroSCORE stratum.

CONCLUSIONS

Aortic valve replacement can be performed in the elderly population with acceptable outcomes. EuroSCORE risk stratification is imprecise for prediction of perioperative mortality among octogenarian AVR patients, but may be useful for predicting mortality during medium-term follow-up.

Excellent outcomes in a case of complex re-do surgery requiring prolonged cardioplegia using a new cardioprotective approach: adenocaine

A 71-year-old high-risk fourth-time redo male patient was diagnosed with prosthetic valve endocarditis of both aortic and mitral valves, and subsequently required a re-operative aortic and mitral valve replacement. He was placed on cardiopulmonary bypass (CPB) and arrested with normothermic hyperkalemic all-blood cardioplegia (microplegia) containing adjunctive adenosine-lidocaine-magnesium (adenocaine); aerobic arrest was maintained with near-continuous retrograde low potassium (approximately 2 mEq/L) adenocaine microplegia. After 4 hours of arrest on CPB, the aortic valve was found to be incompetent and was resected. A root replacement was required utilizing a Medtronic Freestyle Root prosthesis. Four separate periods of cross-clamp were required during the course of the entire operation. The patient was on CPB for 9.8 hours with a total cross-clamp time of 7 hours, during which he received 72 liters of all-blood adenocaine microplegia. After a terminal "hot shot" with adenocaine microplegia and no added potassium, CPB was discontinued with no systemic hyperkalemia (5.1 mmol/L), no hemodilution (hematocrit, 24%), no balloon pump, no antiarrhythmic agents, and modest inotropic support. The patient was hemodynamically stable, was extubated in 12 hours, and was transferred out of the cardiac ICU after 48 hours with a subsequent uneventful recovery.

Interventional therapies for heart failure in the elderly

The aging of a population replete with risk factors for heart failure (HF) (coronary heart disease, diabetes, and hypertension) coupled with a declining age-adjusted mortality rate for coronary artery and hypertensive heart diseases has created, and will continue to create, a literal explosion in the prevalence of HF in the United States. Despite advances in maximal medical therapy, however, most patients who have symptomatic HF can expect functional impairment, interludes of worsening symptomatology, and a shortened lifespan. This article updates the use of interventional therapies for the treatment of elderly patients who have HF caused by coronary artery disease, valvular heart disease, congenital heart disease, myocardial disease, and renal vascular disease.

Interventional therapies for heart failure in the elderly

The aging of a population replete with risk factors for heart failure(HF) (coronary heart disease, diabetes, and hypertension) coupled with a declining age-adjusted mortality rate for coronary artery and hypertensive heart diseases has created, and will continue to create, a literal explosion in the prevalence of HF in the United States. Despite advances in maximal medical therapy, however, most patients who have symptomatic HF can expect functional impairment, interludes of worsening symptomatology, and a shortened lifespan. This article updates the use of interventional therapies for the treatment of elderly patients who have HF caused by coronary artery disease, valvular heart disease, congenital heart disease, myocardial disease, and renal vascular disease.

Cardiac surgery and operative mortality in 1992 and 2002: the St Antonius experience

OBJECTIVE

Comparing the changes in open-heart surgical procedures and hospital mortality in 1992 with 2002.

DESIGN AND SETTING

Retrospective investigation at St Antonius Hospital in Nieuwegein.

METHOD

A comparison of the open-heart surgical procedures, hospital mortality and age distribution of the operated patients was made, using the database of the Department of Cardiothoracic Surgery.

RESULTS

The total number of open-heart surgical procedures increased. There were more combined procedures, aortic valve replacements and reconstructions of the thoracic aorta. The total number of reoperations decreased. In 2002 the use of an arterial conduit for coronary bypass procedures reached 94%, and the radial artery was used for the first time. The mean patient age and the hospital mortality were higher in 2002.

CONCLUSION

Comparing cardiovascular surgery in 1992 to 2002 showed an increase in complicated procedures and older age groups of patients. This may be the reason for higher overall mortality. The mean patient age increased considerably from 1992 to 2002, together with the number of combined procedures and aortic valve replacements with biological valve prostheses. These trends give cardiovascular surgery a challenging future, to treat the patient adequately and keeping the mortality and complication rates low.