Aortic valve replacement with or without concomitant coronary artery bypass grafting in very elderly patients aged 85 years and older

Clinical Outcomes after Surgical Aortic Valve Replacement in 681 Octogenarians: A Single-Center Real-World Experience Comparing the Old Patients with the Very Old Patients

Aortic valve disease is a lethal condition, once it becomes symptomatic. Surgical aortic valve replacement (SAVR) has, for a long time, been the only treatment option. In patients aged 85 and older, the consequences of SAVR have rarely been investigated. A total of 681 octogenarian patients were subdivided into a group with patients between 80 and 84 years (n = 527) and a group with patients aged 85 or older (n = 154). For each group, the temporal referral pattern, preoperative comorbid profile, operative data, postoperative need for resources, and adverse postoperative events including 30-day mortality and long-term survival were determined using the chi-squared test, Student's t-test, and log-rank test. For both age groups, the predictors for mortality were identified using a logistic regression analysis. In the oldest patient group, there were significantly more prior episodes of heart failure (75/154 vs. 148/527) and a greater need for urgent SAVR (45/150 vs. 109/515). The operative data and the need for postoperative resources were comparable, but the 30-day mortality was almost twice as high (24/154 vs. 45/527). The need for urgent SAVR was twice as high in the oldest group (odds ratio of 3.12 vs. 6.64). A logistic regression analysis for all 681 patients showed that age over 85 ranked fourth of six predictors for 30-day mortality. Five-year survival was favorable for both groups (67.8 ± 2.1% vs. 60.0 ± 4.3%). A Cox proportional hazard analysis failed to identify an age over 85 as a predictor for long-term mortality. Aortic valve disease and its effect on the left ventricle seemed to be more advanced in the highest age group. The mortality rate was almost double the need for urgent SAVR. This can be avoided by obtaining an earlier referral.

The impact of coronary artery bypass grafting added to aortic valve replacement on long-term outcomes in octogenarian patients: a reconstructed time-to-event meta-analysis

The long-term results in studies comparing octogenarian patients who received either isolated surgical aortic valve replacement (i-SAVR) or coronary artery bypass grafting (CABG) in addition to SAVR are still debated. We performed a reconstructed time-to-event data meta-analysis of studies comparing i-SAVR and CABG+SAVR to evaluate the impact of CABG and to analyse the time-varying effects on long-term outcome. We performed a systematic review of the literature from January 2000 through November 2021, including studies comparing i-SAVR and CABG+SAVR, which reported at least 3-year follow-up and that plotted Kaplan–Meier curves of overall survival. The primary endpoint was overall long-term survival; secondary endpoints were in-hospital/30-day mortality and postoperative outcomes. The pooled hazard ratio (HR) and odds ratio) with 95% confidence interval (CI) were calculated for primary and secondary endpoints, respectively. Random-effect model was used in all analyses. Sixteen retrospective studies were included (5382 patients, i-SAVR = 2568 and CABG+SAVR = 2814). I-SAVR showed a lower incidence of in-hospital mortality compared to CABG+SAVR (odds ratio = 0.73; 95% CI= 0.60–0.89; P = 0.002). Landmark analyses showed a significantly higher all-cause mortality within 1 year from surgery in CABG+SAVR (HR = 1.17; 95% CI = 1.01–1.36; P = 0.03); after 1 year, no significant difference was observed (HR = 0.95; 95% CI = 0.87–1.04; P = 0.35). Landmark analysis was confirmed by time-varying trend of HR. Late survival of octogenarians did not differ significantly between the 2 interventions. Interestingly, CABG added to SAVR was associated with both higher in-hospital and within 1-year mortality after surgery, whereas this difference was statistically non-significant at long-term follow-up.

The early and long-term outcomes of coronary artery bypass grafting added to aortic valve replacement compared to isolated aortic valve replacement in elderly patients: a systematic review and meta-analysis

In aged population, the early and long-term outcomes of coronary revascularization (CABG) added to surgical aortic valve replacement (SAVR) compared to isolated SAVR (i-SAVR) are conflicting. To address this limitation, a meta-analysis comparing the early and late outcomes of SAVR plus CABG with i-SAVR was performed. Electronic databases from January 2000 to November 2021 were screened. Studies reporting early-term and long-term comparison between the two treatments in patients over 75 years were analyzed. The primary endpoints were in-hospital/30-day mortality and overall long-term survival. The pooled odd ratio (OR) and hazard ratio (HR) with 95% confidence interval (CI) were calculated for in-early outcome and long-term survival, respectively. Random-effect model was used in all analyses. Forty-four retrospective observational studies reporting on 74,560 patients (i-SAVR = 36,062; SAVR + CABG = 38,498) were included for comparison. The pooled analysis revealed that i-SAVR was significantly associated with lower rate of early mortality compared to SAVR plus CABG (OR = 0.70, 95% CI 0.66–0.75; p < 0.0001) and with lower incidence of postoperative acute renal failure (OR = 0.65; 95% CI 0.50–0.91; p = 0.02), need for dialysis (OR = 0.65; 95% CI 0.50–0.86; p = 0.002) and prolonged mechanical ventilation (OR = 0.57; 95% CI 0.42–0.77; p < 0.0001). Twenty-two studies reported data of long-term follow-up. No differences were reported between the two groups in long-term survival (HR = 0.95; 95% CI  0.87–1.03; p = 0.23). CABG added to SAVR is associated with worse early outcomes in terms of early mortality, postoperative acute renal failure, and prolonged mechanical ventilation. Long-term survival was comparable between the two treatments.