Immediate and late outcome of patients aged 80 years and older undergoing isolated aortic valve replacement: a systematic review and meta-analysis of 48 studies

Stroke after heart valve surgery: a single center institution report

INTRODUCTION

Stroke is a potentially debilitating complication of heart valve replacement surgery, with rates ranging from 1 to 10%. Despite advancements in surgical techniques, the incidence of postoperative stroke remains a significant concern, impacting patient outcomes and healthcare resources. This study aims to investigate the incidence, risk factors, and outcomes of in-hospital adverse neurologic events, particularly stroke, following valve replacement. The analysis focuses on identifying patient characteristics and procedural factors associated with increased stroke risk.

METHODS

This retrospective study involves a review of 417 consecutive patients who underwent SVR between January 2004 and December 2022. The study cohort was extracted from a prospectively recorded cardiac intensive care unit database. Preoperative and perioperative data were collected, and subjects with specific exclusion criteria were omitted from the analysis. The analysis includes demographic information, preoperative risk factors, and perioperative variables.

RESULTS

The study identified a 4.3% incidence of postoperative stroke among SVR patients. Risk factors associated with increased stroke susceptibility included prolonged cardiopulmonary bypass time, aortic cross-clamp duration exceeding 90 min, prior stroke history, diabetes mellitus, and mitral valve annulus calcification. Patients undergoing combined procedures, such as aortic valve replacement with mitral valve replacement or coronary artery bypass grafting with AVR and MVR, (OR = 10.74, CI:2.65-43.44, p-value = < 0.001) and (OR = 11.66, CI:1.02-132.70, p-value = 0.048) respectively, exhibited elevated risks. Internal carotid artery stenosis (< 75%) and requiring prolonged inotropic support were also associated with increased stroke risk(OR = 3.04, CI:1.13-8.12, P-value = 0.026). The occurrence of stroke correlated with extended intensive care unit stay (OR = 1.12, CI: 1.04-1.20, P-value = 0.002) and heightened in-hospital mortality.

CONCLUSION

In conclusion, our study identifies key risk factors and underscores the importance of proactive measures to reduce postoperative stroke incidence in surgical valve replacement patients.

Preoperative cognition predicts clinical stroke/TIA and mortality after surgical aortic valve replacement in older adults

Stroke and death remain risks of surgical aortic valve replacement (SAVR). Preoperative cognitive screeners repeatedly show that reduced scores predict postoperative outcome, but less is known about comprehensive neuropsychological measures predicting risk. This study had two aims: 1) investigate whether preoperative cognitive measures predicted postoperative clinical stroke/transient ischemic attack (TIA) and mortality in older adults undergoing SAVR, and 2) identify the best predictors within a comprehensive cognitive protocol. A total of 165 participants aged 65 + with moderate-to-severe aortic stenosis completed a comprehensive cognitive test battery preoperatively. Postoperative stroke evaluations were conducted by trained stroke neurologists preoperatively and postoperatively, and mortality outcomes were obtained by report and records. Logistic regressions were conducted to evaluate preoperative cognitive predictors of clinical stroke/TIA within 1 week of surgery and mortality within 1 year of surgery. Multivariate models showed measures of delayed verbal memory recall (OR = 0.86; 95% CI 0.74-0.99) and visuospatial skills (OR = 0.95; 95% CI 0.90-1.01) predicted clinical stroke/TIA within 1 week of surgery, R2 = .41, p < .001, ƒ2 = .69. Measures of naming ability (OR = 0.88; 95% CI 0.80-0.96), verbal memory recall (OR = 1.23; 95% CI 0.99-1.51), visual memory recall (OR = 0.90; 95% CI 0.80-1.00), medical comorbidities (OR = 1.71; 95% CI 1.22-2.65), and sex (OR = 2.39; 95% CI 0.90-7.04) were significant predictors of death within 1 year of surgery, R2 = .68, p < .001, ƒ2 = 2.12. Preoperative cognitive measures reflecting temporal and parietal lobe functions predicted postoperative clinical stroke/TIA within 1 week of SAVR and mortality within 1 year of SAVR. As such, cognitive measures may offer objective and timely indicators of preoperative health, specifically vulnerabilities in cerebral hypoperfusion, which may inform intervention and/or intensive postoperative monitoring and follow-up after SAVR.

Association of Preoperative Geriatric Assessment With Length of Stay After Combined Cardiac Surgery

BACKGROUND

For older patients undergoing cardiac surgery, geriatric factors are known to increase postoperative complications and prolong length of stay (LOS). Comprehensive geriatric assessment (CGA) is an evidence-based method for geriatric evaluation to develop an individualized-care plan to optimize physical, functional, and social issues. This study analyzed the association between preoperative CGA and hospital LOS after combined cardiac surgery.

METHODS

This retrospective monocentric study included all patients aged 75 years and greater who underwent combined cardiac surgery between 2014 and 2017. Hospital LOS, intensive care unit LOS, and postoperative complications were compared between patients with or without preoperative CGA before and after propensity-score matching.

RESULTS

Mean age of the 407 patients was 79.6 years; 114 underwent a preoperative CGA (28%). For 305 patients (74.9%), coronary artery bypass was associated with aortic valve replacement. After propensity-score matching, a significant difference was found between the 2 groups (preoperative CGA versus none) for in-hospital LOS (12 versus 13 days; P = .04) and intensive care unit LOS (3 versus 4 days; P = .01). In multivariable analysis, a significant association remained between hospital LOS and CGA (P = .02), renal function (P = .02), mitral replacement (P = .001), and complications (P = .001).

CONCLUSIONS

Our results favor the use of systematic preoperative CGA. These encouraging results need to be validated by prospective studies that assess the impact of individualized-care plan established after CGA on postoperative outcomes. With an aging population, efforts are required to determine how to implement preoperative individualized-care plans to improve postoperative outcomes for vulnerable patients undergoing cardiac surgery.

Timing of Recognition for Perioperative Strokes Following Cardiac Surgery

INTRODUCTION

More than half of reported perioperative strokes following cardiac surgery are identified beyond postoperative day one. The objective of our study was to determine preoperative and intraoperative factors that are associated with stroke following cardiac surgery and to identify factors that may contribute delayed recognition of perioperative stroke.

METHODS

Patients undergoing coronary artery bypass surgery or isolated valve surgery from January 2, 2015 to April 28, 2017 at an academic health system were identified from the Society of Thoracic Surgeons Registry. We determined preoperative and intraoperative factors associated with perioperative stroke. Two neurologists performed retrospective chart reviews on perioperative stroke patients to determine the last seen well time and the stroke cause.

RESULTS

During the study period, 2795 patients underwent coronary artery bypass surgery or isolated valve surgery (mean age 64 ± 11 years, 71% male, 72% Caucasian, 9% history of stroke), of which 43 (1.5%) had a perioperative stroke; 31 (72%) patients had an embolic mechanism of stroke based on neuroimaging. In multivariable analysis, perioperative strokes were independently associated with increasing age (OR 1.04, 95% 1.01-1.07), history of stroke (OR 2.73, 95% CI 1.47-5.06), and history of thoracic aorta disease (OR 3.36, 95% CI 1.16-9.71). Strokes were identified after postoperative day one in 32 (74%) patients of which 26 (81%) had a preoperative last seen well time.

CONCLUSION

Given the high frequency of preoperative last seen well time in perioperative stroke patients who are identified after postoperative day one, delayed stroke recognition may contribute to the bimodal distribution in timing of perioperative stroke. Frequent neurological monitoring within 24 hours after CABG or isolated valve surgery should be considered for all patients undergoing cardiac surgery, particularly elderly patients and those with a history of stroke or thoracic aorta disease, to improve early stroke recognition.

Age-dependent morbidity and mortality outcomes after surgical aortic valve replacement

OBJECTIVES

This study addressed the assumption of increased morbidity and mortality after surgical aortic valve replacement in patients older than 80 years with severe aortic stenosis.

METHODS

This prospective study was performed in consecutive patients referred for aortic valve replacement. The age-dependent change in cognitive and physical function, quality of life and rehospitalization and complication rates during the following year and 5-year all-cause mortality were documented.

RESULTS

A total of 351 patients underwent surgical aortic valve replacement. The death risk at 5 years was 10%, 20% and 34% in patients aged <70 years, 70-79 years and ≥80 years, respectively. Patients aged 70-79 years and ≥80 years had a hazard ratio of 1.88 [95% confidence interval (95% CI) 0.92-3.83, P = 0.08] and 2.90 [95% CI 1.42-5.92, P = 0.003] for mortality, respectively, when compared with patients aged <70 years. The length of stay and rehospitalization rate during the following year were similar between the groups. Patients ≥80 years of age experienced more delirium and infections, whereas the risks of new pacemaker, transient ischaemic attack (TIA) or stroke, myocardial infarction and heart failure were comparable between the age groups. All groups exhibited reduced New York Heart Association class, improved physical quality of life and unchanged mental scores without any clinically significant Mini Mental Status reduction.

CONCLUSIONS

Elderly patients (≥80 years of age) have important gains in health measures and satisfactory 5-year survival with an acceptable complications rate during the year following surgery. Active respiratory mobilization and the removal of an indwelling urethra catheter can prevent adverse effects, and measures should be taken to prevent delirium and confusion in elderly patients.

Clinical trial registration

clinicaltrials.gov (NCT 01794832).

Geriatric factors associated with 1-year mortality after aortic valve replacement

BACKGROUND

Surgical aortic valve replacement has been shown to improve survival and quality of life in patients with severe aortic stenosis. However, clinical variables are known to be associated with an increased mortality rate. As geriatric conditions are highly prevalent in this older population, the aim of this study was to identify geriatric factors associated with 1-year mortality after a surgical aortic valve replacement among older patients with severe symptomatic aortic stenosis.

METHODS

Between January 2012 and September 2014, all patients ≥ 75 years referred for a surgical aortic valve replacement after a complete pre-operative evaluation in a university-affiliated center were included in this observational study. Association between 1-year mortality surgical aortic valve replacement and baseline characteristics including cardiac and geriatric factors was analysed by Cox models.

RESULTS

Mean age of the 197 patients studied was 81.3 ± 3.5 years and 48.2% were men. At 1 year of the intervention, 19 patients (9.6%) were dead. On multivariate analysis, previous cardiac surgery (Hazard ratio [HR] = 10.47, p = 0.03), undergoing concomitant cardiac surgery (HR = 6.22, p = 0.03), pulmonary hypertension (HR = 3.73, 0.04) were still associated with 1-year mortality. Moreover, cognitive impairment was also associated with 1-year mortality (HR = 4.67, p = 0.04).

CONCLUSIONS

This study is the first study to show that among geriatric factors, cognitive impairment was a strong predictor of 1-year mortality after a surgical aortic valve replacement in patients aged 75 years old and older, independently of other geriatric and cardiac factors. This study highlights the importance of pre-operative cognitive assessment.

Surgical treatment of elderly patients with severe aortic stenosis in the modern era - review

Surgical treatment of severe aortic stenosis offers good early and long-term results, even in elderly patients. Despite the implementation of percutaneous methods for the very high-risk group, surgical valve replacement remains the gold standard. The advanced age of patients should not be the only indicator limiting the possibility of surgery. In this review we present the most important information on the results of aortic stenosis surgical treatment in the groups of older patients. New methods such as percutaneous and minimally invasive methods of surgery are also discussed. Additionally, the presented information is referred to current guidelines for the treatment of severe aortic stenosis.

Temporal Trends and Clinical Consequences of Wait Times for Transcatheter Aortic Valve Replacement

Background:

Transcatheter aortic valve replacement (TAVR) represents a paradigm shift in the therapeutic options for patients with severe aortic stenosis. However, rapid and exponential growth in TAVR demand may overwhelm capacity, translating to inadequate access and prolonged wait times. Our objective was to evaluate temporal trends in TAVR wait times and the associated clinical consequences.

Methods:

In this population-based study in Ontario, Canada, we identified all TAVR referrals from April 1, 2010, to March 31, 2016. The primary outcome was the median total wait time from referral to procedure. Piecewise regression analyses were performed to assess temporal trends in TAVR wait times, before and after provincial reimbursement in September 2012. Clinical outcomes included all-cause death and heart failure hospitalizations while on the wait list.

Results:

The study cohort included 4461 referrals, of which 50% led to a TAVR, 39% were off-listed for other reasons, and 11% remained on the wait list at the conclusion of the study. For patients who underwent a TAVR, the estimated median wait time in the postreimbursement period stabilized at 80 days and has remained unchanged. The cumulative probability of wait-list mortality and heart failure hospitalization at 80 days was ≈2% and 12%, respectively, with a relatively constant increase in events with increased wait times.

Conclusions:

Postreimbursement wait time has remained unchanged for patients undergoing a TAVR procedure, suggesting the increase in capacity has kept pace with the increase in demand. The current wait time of almost 3 months is associated with important morbidity and mortality, suggesting a need for greater capacity and access.

Surgical Aortic Valve Replacement in Octogenerians in the Era of Transcatheter Aortic Valve Replacement

BACKGROUND

The hospital mortality rate in >80-year-old patients undergoing surgical aortic valve replacement (SAVR) is reportedly satisfactory, but how such patients' functional status both at discharge and during the postoperative hospitalization period might affect their quality of life and medical costs remains unclear.Methods and Results:The adverse events of 161 patients aged >80 years who underwent SAVR with or without coronary artery bypass grafting were retrospectively investigated. Adverse events were defined as hospital death, a long hospital stay (>60 days) attributable to major complications or requirement for rehabilitation, or a depressed status at discharge (modified Rankin scale score >4). A total of 18.6% of patients developed adverse events, and their hospital mortality rate was 4.3%. Logistic regression analysis revealed that a perfusion time >3 h (P=0.0331; odds ratio, 2.685) and EuroSCORE II >10% (P<0.0001; odds ratio, 8.232) were significant risk factors for adverse events. The average medical cost was approximately 1.5-fold higher in patients with adverse events (¥8,360,880 vs. ¥5,234,660, P=0.0016).

CONCLUSIONS

Clinical findings focusing on status at discharge and during postoperative hospitalization of SAVR in patients aged >80 years was relatively high compared with hospital mortality, especially in patients with a longer perfusion time and high EuroSCORE. Further studies are necessary to define the indications for SAVR in patients aged >80 years in the era of transcatheter AVR.

Functionality and Outcome in Older Patients with Severe Aortic Stenosis (FOOPAS): an interdisciplinary study concept for a prospective trial

Background

Frailty is a geriatric syndrome that can influence mortality and functional recovery after treatment of severe aortic stenosis (AS). The integration of standardized geriatric assessment (GA) in clinical practice is limited by a lack of consensus on how to measure it.

Objectives

This study aims to compare the incremental predictive value of different frailty scales to predict the outcomes following surgical aortic valve replacement, transcatheter aortic valve implantation, and conservative treatment of severe AS.

Methods

A prospective cohort of 300 older adults with severe AS will be assembled after standard clinical examinations and a comprehensive GA, including 18 different tests and values. Primary outcome parameters are overall mortality, cardiovascular mortality, quality of life, and functionality. Secondary parameters are overall complications, cardiovascular complications, and costs.

Results

Expected results will contribute to the growing body of evidence on frailty based on parameters that influence clinical and functional outcome in elderly patients independent of the method of treatment. The pre-procedural assessment is expected to be valuable in discriminating new post-procedural complications from simple exacerbations of pre-existing conditions. Therefore, a new frailty test which is simple and feasible for application in a clinical routine by most medical professionals, may help in identifying patients for whom further GA should be considered. Finally, such a frailty score could support heart teams to find the right treatment for patients suffering from AS.

Conclusion

Comparison of different frailty scales has not only the goal of finding a predictive value of mortality but also to bring in a meaningful improvement for each individual patient and to avoid disability or fatal outcomes.

Transcatheter aortic valve implantation versus surgical aortic valve replacement in patients over 85 years old

OBJECTIVES

Surgical aortic valve replacement (SAVR) for the treatment of in very old patients with severe aortic stenosis is associated with a high risk of morbidity and mortality. Transcatheter aortic valve implantation (TAVI) has become the preferred alternative. Therefore, we sought to evaluate outcomes in very old patients who underwent SAVR versus TAVI.

METHODS

A total of 169 consecutive patients aged ≥85 years underwent TAVI (n = 68) or SAVR (n = 101). A propensity score adjustment was used to compare outcomes including cost analysis.

RESULTS

The propensity score generated 40 pairs of patients with similar baseline characteristics. The TAVI group experienced atrioventricular block (37.5% vs 5%, P < 0.01) more frequently, a longer stay in the intensive care unit (median 5 days, range 1-35 vs median 2 days, range 1-6, P < 0.01) but a lower rate of new-onset atrial fibrillation (15% vs 47.5%, P < 0.01). The 30-day mortality rate was similar in the unmatched and matched cohorts (8.8% vs 5.0%, P = 0.32; 10% vs 7.5%, P = 0.69). One, 3- and 5-year overall survival rates (80% vs 90%, 56% vs 79%, 37% vs 71%, P < 0.01) and freedom from major adverse cardiac and cardiovascular events (72% vs 90%, 46% vs 76%, 17% vs 68%, P < 0.01) were lower in the TAVI group. An overall cost analysis indicated that TAVI was more expensive (€2084 vs €19 891).

CONCLUSIONS

In patients 85 years and older, SAVR seems to offer good short- and mid-term clinical outcomes compared to TAVI. Advanced age alone would not be an indication for TAVI in old-old patients.

Comparison of the Outcomes between Surgical Aortic Valve Replacement and Transcatheter Aortic Valve Replacement in Patients Aged above 80

Background

Transcatheter aortic valve replacement (TAVR) has been suggested as a less invasive treatment for high-risk patients with aortic valve disease. In this study, we compared the outcomes of conventional surgical aortic valve replacement (AVR) and TAVR in elderly patients aged over 80.

Methods

A total of 108 patients aged 80 years or older who underwent isolated AVR (n=35) or TAVR (n=73) from 2010 through 2015 at Asan Medical Center were identified. Early and late clinical outcomes, including echocardiographic findings, were evaluated in both groups. The mean follow-up duration was 766.4±528.7 days in the AVR group and 755.2±546.6 days in the TAVR group, and the average timing of the last follow-up echocardiography was at 492.6±512.5 days in the AVR group and 515.7±526.8 days in the TAVR group.

Results

The overall early mortality was 2.8% (0 of 35, 0% in the AVR group vs. 3 of 73, 4.1% in the TAVR group). Permanent pacemaker insertion was significantly more common in the TAVR group (p=0.010). Renal failure requiring dialysis and new-onset atrial fibrillation was more frequent and the length of hospital stay was longer in the AVR group; however, this difference did not reach statistical significance. In the TAVR group, 14 patients (19.2%) were rehospitalized due to cardiac problems, and 13 patients (17.8%) had developed significant paravalvular leakage by the time of the last follow-up echocardiography.

Conclusion

TAVR could be a good alternative to conventional surgical AVR in elderly patients. However, TAVR has several shortcomings, such as frequent significant paravalvular leakage or readmission, which should be considered in decision-making.

ANMCO/SIC/SICI-GISE/SICCH Executive Summary of Consensus Document on Risk Stratification in elderly patients with aortic stenosis before surgery or transcatheter aortic valve replacement

Aortic stenosis is one of the most frequent valvular diseases in developed countries, and its impact on public health resources and assistance is increasing. A substantial proportion of elderly people with severe aortic stenosis is not eligible to surgery because of the advanced age, frailty, and multiple co-morbidities. Transcatheter aortic valve implantation (TAVI) enables the treatment of very elderly patients at high or prohibitive surgical risk considered ineligible for surgery and with an acceptable life expectancy. However, a significant percentage of patients die or show no improvement in quality of life (QOL) in the follow-up. In the decision-making process, it is important to determine: (i) whether and how much frailty of the patient influences the risk of procedures; (ii) how the QOL and the individual patient's survival are influenced by aortic valve disease or from other associated conditions; and (iii) whether a geriatric specialist intervention to evaluate and correct frailty or other diseases with their potential or already manifest disabilities can improve the outcome of surgery or TAVI. Consequently, in addition to risk stratification with conventional tools, a number of factors including multi-morbidity, disability, frailty, and cognitive function should be considered, in order to assess the expected benefit of both surgery and TAVI. The pre-operative optimization through a multidisciplinary approach with a Heart Team can counteract the multiple damage (cardiac, neurological, muscular, respiratory, and kidney) that can potentially aggravate the reduced physiological reserves characteristic of frailty. The systematic application in clinical practice of multidimensional assessment instruments of frailty and cognitive function in the screening and the adoption of specific care pathways should facilitate this task.

Transcatheter Aortic Valve Implantation Compared With Surgical Aortic Valve Replacement in Low-Risk Patients

BACKGROUND

The proven efficacy of transcatheter aortic valve implantation (TAVI) in high-risk patients is leading to the expansion of its indications toward lower-risk patients. However, this shift is not supported by meaningful evidence of its benefit over surgical aortic valve replacement (SAVR). This analysis aims to describe outcomes of TAVI versus SAVR in low-risk patients.

METHODS AND RESULTS

We compared the outcome after TAVI and SAVR of low-risk patients (European System for Cardiac Operative Risk Evaluation II [EuroSCORE II] <4%) included in the Observational Study of Effectiveness of SAVR-TAVI Procedures for Severe Aortic Stenosis Treatment (OBSERVANT) study. The primary outcome was 3-year survival. Secondary outcomes were early events and major adverse cardiac and cerebrovascular events at 3 years. Propensity score matching resulted in 355 pairs of patients with similar baseline characteristics. Thirty-day survival was 97.1% after SAVR and 97.4% after TAVI (P=0.82). Cardiac tamponade, permanent pacemaker implantation, major vascular damage, and moderate-to-severe paravalvular regurgitation were significantly more frequent after TAVI compared with SAVR. Stroke rates were equal in the study groups. SAVR was associated with higher risk of cardiogenic shock, severe bleeding, and acute kidney injury. At 3 years, survival was 83.4% after SAVR and 72.0% after TAVI (P=0.0015), whereas freedom from major adverse cardiac and cerebrovascular events was 80.9% after SAVR and 67.3% after TAVI (P<0.001).

CONCLUSIONS

In patients with low operative risk, significantly better 3-year survival and freedom from major adverse cardiac and cerebrovascular events were observed after SAVR compared with TAVI. Further studies on new-generation valve prostheses are necessary before expanding indications of TAVI toward lower-risk patients.

Cognitive Outcomes of Cardiovascular Surgical Procedures in the Old: An Important but Neglected Area

Older individuals can now undergo invasive cardiovascular procedures without serious concern about mortality, and the numbers and proportions of the over 65s and 85s doing so in Australia has been increasing over the last 20 years. There is overwhelming evidence linking cardiovascular conditions to late-life (65 years and over) cognitive impairment and dementia including Alzheimer's Disease, primarily due to impaired cerebrovascularisation and cascading neuropathological processes. Somewhat paradoxically, these cardiovascular interventions, carried out with the primary aim of revascularisation, are not usually associated with short- or long-term improvements in cognitive function in older adults. We discuss factors associated with cognitive outcomes post-cardiovascular surgeries in patients over 65 years of age. There are many opportunities for future research: we know almost nothing about cognitive outcomes following invasive cardiac procedures in the oldest old (85 years and over) nor how to predict the cognitive/delirium outcome using pre-surgical data, and lastly, intervention opportunities exist both pre and postoperatively that have not been tested. As our population ages with increased cardiovascular burden and rates of cardiovascular interventions and surgeries, it is critical that we understand the cognitive consequences of these procedures, who is at greatest risk, and ways to optimise cognition.

Heart valve disease in elderly Chinese population: effect of advanced age and comorbidities on treatment decision-making and outcomes

Background

A considerable proportion of elderly patients with symptomatic severe heart valve disease are treated conservatively despite clear indications for surgical intervention. However, little is known about how advanced age and comorbidities affect treatment decision-making and therapeutic outcomes.

Methods

Patients (n = 234, mean age: 78.5 ± 3.7 years) with symptomatic severe heart valve disease hospitalized in our center were included. One hundred and fifty-one patients (65%) were treated surgically (surgical group) and 83 (35%) were treated conservatively (conservative group). Factors that affected therapeutic decision-making and treatment outcomes were investigated and long-term survival was explored.

Results

Isolated aortic valve disease, female sex, chronic renal insufficiency, aged ≥ 80 years, pneumonia, and emergent status were independent factors associated with therapeutic decision-making. In-hospital mortality for the surgical group was 5.3% (8/151). Three patients (3.6%) in the conservative group died during initial hospitalization. Low cardiac output syndrome and chronic renal insufficiency were identified as predictors of in-hospital mortality in the surgical group. Conservative treatment was identified as the single risk factor for late death in the entire study population. The surgical group had better 5-year (77.2% vs. 45.4%, P < 0.0001) and 10-year (34.5% vs. 8.9%, P < 0.0001) survival rates than the conservative group, even when adjusted by propensity score-matched analysis.

Conclusions

Advanced age and geriatric comorbidities profoundly affect treatment decision-making for severe heart valve disease. Valve surgery in the elderly was not only safe but was also associated with good long-term survival while conservative treatment was unfavorable for patients with symptomatic severe valve disease.

Aortic valve replacement with sutureless and rapid deployment aortic valve prostheses

Aortic valve stenosis is the most common valve disease in the western world. Over the past few years the number of aortic valve replacement (AVR) interventions has increased with outcomes that have been improved despite increasing age of patients and increasing burden of comorbidities. However, despite such excellent results and its well-established position, conventional AVR has undergone great development over the previous two decades. Such progress, by way of less invasive incisions and use of new technologies, including transcatheter aortic valve implantation and sutureless valve prostheses, is intended to reduce the traumatic impact of the surgical procedure, thus fulfilling lower risk patients' expectations on the one hand, and extending the operability toward increasingly high-risk patients on the other. Sutureless and rapid deployment aortic valves are biological, pericardial prostheses that anchor within the aortic annulus with no more than three sutures. The sutureless prostheses, by avoiding the passage and the tying of the sutures, significantly reduce operative times and may improve outcomes. However, there is still a paucity of robust, evidence-based data on the role and performance of sutureless AVR. Therefore, strongest long-term data, randomized studies and registry data are required to adequately assess the durability and long-term outcomes of sutureless aortic valve replacement.

Therapeutic Decision-Making for Elderly Patients With Symptomatic Severe Valvular Heart Diseases

The aim of this study was to determine how older age and co-morbidities affect the treatment decision-making and long-term survival in elderly patients with symptomatic severe valvular heart diseases.A total of 181 elderly patients (mean age, 78.4 ± 3.4 years) hospitalized between January 2003 and June 2012 with symptomatic severe valvular heart diseases were enrolled. Cardiac and geriatric factors associated with treatment decision-making were analyzed. Survival outcomes were investigated.Surgical treatment was performed in 116 (64%) patients (surgical group) and 65 patients (36%) were treated conservatively (conservative group). The most common [62% (40/65)] reason for refusing surgical treatment was high operative risk as assessed by the physicians who initially cared for the patients. Multivariate logistic regression analysis identified female gender, chronic renal insufficiency, older age, pneumonia, and emergent status as independent predictors of the conservative treatment. Patients with isolated aortic valve disease tended to undergo an operation. Overall 5-year survival in the surgical group was 76.8% versus 42.9% in the conservative group (P < 0.0001). After matching using the propensity score, the surgical group still had a better long-term survival than the conservative group (P = 0.001). Cox regression analysis revealed conservative treatment as the single risk factor associated with poor long-term survival in all series.Approximately 40% of the elderly patients with symptomatic severe heart valve disease were treated conservatively despite a definite indication for surgical intervention. Cardiac and geriatric co-morbidities profoundly affect the treatment decision-making. Interdisciplinary discussion should be encouraged to optimize therapeutic options for elderly patients with valvular heart disease.

Predictive factors of long-term survival in the octogenarian undergoing surgical aortic valve replacement: 12-year single-centre follow-up

The improvement of life expectancy created more surgical candidates with severe symptomatic aortic stenosis and age >80. Therefore, the main objective of this observational, retrospective single-centre study is to compare the long-term survival of octogenarians that have undergone surgical aortic valve replacement (AVR) to the survival of the general population of the same age and to establish whether any perioperative characteristics can anticipate a poor long-term result, limiting the prognostic advantage of the procedure at this age. From 2000 to 2014, 264 octogenarians underwent AVR at our institution. Perioperative data were retrieved from our institutional database and patients were followed up by telephonic interviews. The follow-up ranged between 2 months and 14.9 years (mean 4.1 ± 3.1 years) and the completeness was 99.2 %. Logistic multivariate analysis and Cox regression were respectively applied to identify the risk factors of in-hospital mortality and follow-up survival. Our patient population ages ranged between 80 and 88 years. Isolated AVR (I-AVR) was performed in 136 patients (51.5 %) whereas combined AVR (C-AVR) in 128 patients (48.5 %). Elective procedures were 93.1 %. Logistic EuroSCORE was 15.4 ± 10.6. In-hospital mortality was 4.5 %. Predictive factors of in-hospital mortality were the non-elective priority of the procedure (OR 5.7, CI 1.28-25.7, p = 0.02), cardiopulmonary bypass time (OR 1.02, CI 1.01-1.03, p = 0.004) and age (OR 1.36, CI 1.01-1.84, p = 0.04). Follow-up survival at 1, 4, 8 and 12 years was 93.4 % ± 1.6 %, 72.1 % ± 3.3 %, 39.1 % ± 4.8 % and 20.1 % ± 5.7 %, respectively. The long-term survival of these patients was not statistically different from the survival of an age/gender-matched general population living in the same geographic region (p = 0.52). Predictive factors of poor long-term survival were diabetes mellitus (HR 1.55, CI 1.01-2.46, p = 0.05), preoperative creatinine >200 μmol/L (HR 2.07, CI 1.21-3.53, p = 0.007) and preoperative atrial fibrillation (HR 1.79, CI 1.14-2.80, p = 0.01). In our experience, AVR can be safely performed in octogenarians. After a successful operation, the survival of these patients returns similar to the general population. Nevertheless, the preoperative presence of major comorbidities such as diabetes mellitus, renal dysfunction and atrial fibrillation significantly impact on long-term results.

Comparison of Preoperative and Postoperative Characteristics in Octogenarians Having Isolated Surgical Aortic Valve Replacement Before Versus After Introduction of Transcatheter Aortic Valve Implantation

Aortic stenosis (AS) is the most frequent heart valve disease. Surgical aortic valve replacement (SAVR) is the reference treatment. Transcatheter aortic valve implantation (TAVI) has emerged as an alternative treatment. New strategies for treating the AS are upcoming. The aim of the study was to assess if the clinical profile of octogenarian patients treated surgically before and after the TAVI program initiation has changed. We retrospectively included consecutive octogenarian patients, who underwent isolated SAVR, from January 2006 to December 2011 in a single high-volume center. We compared preoperative and postoperative characteristics before and after the initiation of TAVI (February 2009). Five hundred seventeen patients were included: 229 in the "pre-TAVI" group (2006 to 2008), 288 in the "post-TAVI" group (2009 to 2011). The mean age was 83.2 ± 2.0 in the "pre-TAVI" group, 83.5 ± 2.1 in the "post-TAVI" group (p = 0.106). There were no significant differences in preoperative characteristics: New York Heart Association class (p = 0.374), history of heart failure (p = 0.680), left ventricular ejection fraction (59.8 ± 12.2% in the "pre-TAVI" group, 59.9 ± 11.3% in the "post-TAVI" group, p = 0.922), coronary artery disease (p = 0.431), chronic pulmonary disease (p = 0.363), and previous cardiac surgery (p = 0.085). The logistic EuroSCORE was 7.78 ± 4.60% in the "pre-TAVI" group and 7.33 ± 3.96% in the "post-TAVI" group (p = 0.236). The operative mortality (30-day) was comparable: 5.2% in the "pre-TAVI" group, 6.9% in the "post-TAVI" group (p = 0.424). Thus, with the emergence of TAVI, the number of octogenarian patients operated on, their preoperative characteristics, and the operative mortality remained comparable.

Comparison of Outcome of Transcatheter Aortic Valve Implantation With Versus Without Previous Coronary Artery Bypass Grafting (from the FRANCE 2 Registry)

Previous coronary artery bypass grafting (CABG) increases operative risk in conventional valve replacement. Transcatheter aortic valve implantation (TAVI) has been shown to be successful in high-risk patient subgroups. The present study compared outcome and overall survival in patients who underwent TAVI with and without history of CABG. From January 2010 to December 2011, 683 of the 3,761 patients selected for TAVI in 34 French centers (18%) had a history of CABG. Outcomes (mortality and complications) were collected prospectively according to the Valve Academic Research Consortium (VARC) criteria. Patients with previous CABG were younger, with higher rates of diabetes and vascular disease and higher logistic European System for Cardiac Operative Risk Evaluation (29.8 ± 16.4 vs 20.1 ± 13.0, p <0.001) but lower rates of pulmonary disease. Two types of valve (Edwards SAPIEN and Medtronic CoreValve) were implanted in equal proportions in the 2 groups. The 30-day and 1-year mortality rates from all causes on Kaplan-Meier analysis (9.2% vs 9.7%, p = 0.71; and 19.0% vs 20.2%, p = 0.49, respectively) did not differ according to the history of CABG. There were no significant differences in the Valve Academic Research Consortium complications (myocardial infarction, stroke or vascular, and bleeding complications). On multivariate analysis, CABG was not associated with greater 1-year post-TAVI mortality. In conclusion, previous CABG did not adversely affect outcome in patients who underwent TAVI, which may be an alternative to surgery in high-risk patients with severe aortic stenosis and history of CABG.

Nontransfemoral Approaches to Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) is noninferior to surgical aortic valve replacement in patients with high operative risk and superior to medical treatment in patients deemed unsuitable for surgical intervention. However, up to 30% to 50% of patients screened for this intervention are not candidates for TAVR via the preferred transfemoral route because of severe peripheral arterial disease. Alternative access routes must be considered and include the transapical, transaortic, transsubclavian, and transcarotid approaches. The use of alternative access is predicated on appropriate patient selection as determined by a dedicated multispecialty heart valve team and can lead to excellent outcomes.

[Epidemiology of cerebral perioperative vascular accidents]

OBJECTIVES

Stroke is a well-described postoperative complication, after carotid and cardiac surgery. On the contrary, few studies are available concerning postoperative stroke in general non-cardiac non-carotid surgery. The high morbid-mortality of stroke justifies an extended analysis of recent literature.

ARTICLE TYPE

Systematic review.

DATA SOURCES

Firstly, Medline and Ovid databases using combination of stroke, cardiac surgery, carotid surgery, general non-cardiac non-carotid surgery as keywords; secondly, national and European epidemiologic databases; thirdly, expert and French health agency recommendations; lastly, reference book chapters.

RESULTS

In cardiac surgery, with an incidence varying from 1.2 to 10% according to procedure complexity, stroke occurs peroperatively in 50% of cases and during the first 48 postoperative hours for the others. The incidence of stroke after carotid surgery is 1 to 20% according to the technique used as well as operator skills. Postoperative stroke is a rare (0.15% as mean, extremes around 0.02 to 1%) complication in general surgery, it occurs generally after the 24-48th postoperative hours, exceptional peroperatively, and 40% of them occurring in the first postoperative week. It concerned mainly aged patient in high-risk surgeries (hip fracture, vascular surgery). Postoperative stroke was associated to an increase in perioperative mortality in comparison to non-postoperative stroke operated patients.

CONCLUSION

Postoperative stroke is a quality marker of the surgical teams' skill and has specific onset time and induces an increase of postoperative mortality.

Aortic valve replacement in octogenarians with prior cardiac surgery

BACKGROUND

Transcatheter aortic valve implantation (TAVI) has been advocated for very elderly patients with aortic stenosis, and prior cardiac surgery as a less invasive treatment option. Although surgical aortic valve replacement (AVR) is safe and effective in selected elderly patients, the perioperative and mid-term outcomes of AVR in very elderly with prior cardiac surgery are unknown.

METHODS

The Society of Thoracic Surgeons (STS) Database at our center enrolled 3,735 patients after AVR since 1997. In this time interval, we identified 61 patients 80 years and older who underwent AVR for severe AS or failed aortic bioprosthesis after having prior cardiac surgery. All clinical parameters were derived from the STS database. Follow-up mortality was assessed using the Social Security Death Index.

RESULTS

The average age of the patients was 83 ± 2 years, 77% were male, and 75% underwent an isolated coronary artery bypass graft (CABG) as their first cardiac procedure. The mean ejection fraction was 0.53 ± 0.13. The CABG was performed concurrently in 49% of patients at the time of redo sternotomy and AVR. Stented bioprosthesis was implanted in 61% of patients and stentless in 39%. Perioperative mortality was 1.6% (1 of 61). One, 3, 5, and 7 year survival rates were 85%, 69%, 63%, and 43%, respectively. Patients with AVR only had similar survival to patients who underwent concomitant AVR and CABG. Type of aortic prosthesis did not influence postoperative survival.

CONCLUSIONS

In selected patients over the age of 80 with history of prior cardiac surgery, AVR can be performed safely with very good mid-term outcomes. Age alone should not be exclusion criteria for surgical AVR in octogenarians with prior cardiac surgery.

[Asymptomatic severe aortic stenosis: a reopened debate]

Aortic stenosis is a complex disease. About 2-7% of the population over 65 years of age is affected by its degenerative form. In patients with severe aortic stenosis presenting with symptoms or left ventricle ejection fraction (LVEF)<.50, aortic valve replacement is indicated. Management and timing of surgery in asymptomatic patients with preserved LVEF is still a matter of debate. Recent published data show that about one third of these patients present with low left ventricle stroke volume, which may affect survival. For this reason, and considering that aortic valve replacement is in most cases a low risk procedure, early surgery in this subgroup is a strategy that deserves to be taken into account. In this review we report on these recent findings, which allow understanding why patients with asymptomatic severe aortic stenosis should not be considered and treated as a homogenous population.

Geriatric cardiac surgery: chronology vs. biology

Cardiac surgery is increasingly performed in elderly patients, and whilst the incidence of common risk factors associated with poorer outcome increases with age, recent studies suggest that outcomes in this population may be better than is widely appreciated. As such, in this review we have examined the current evidence for common cardiac surgical procedures in patients aged over 70 years. Coronary artery bypass grafting (CABG) in the elderly has similar early safety to percutaneous intervention, though repeat revascularisation is lower. Totally avoiding instrumentation of the ascending aorta with off-pump techniques may also reduce the incidence of neurological injury. Aortic valve replacement (AVR) significantly improves quality of life and provides excellent short- and long-term outcomes. Combined AVR and CABG carries higher risk but late survival is still excellent. Mini-sternotomy AVR in the elderly can provide comparable survival to full-sternotomy AVR. More accurate risk stratification systems are needed to appropriately select patients for transcatheter aortic valve implantation. Mitral valve repair is superior to replacement in the elderly, although choosing the most effective method is important for achieving maximal quality of life. Minimally-invasive mitral valve surgery in the elderly has similar postoperative outcomes to sternotomy-based surgery, but reduces hospital length of stay and return to activity. In operative candidates, surgical repair is superior to percutaneous repair. Current evidence indicates that advanced age alone is not a predictor of mortality or morbidity in cardiac surgery. Thus surgery should not be overlooked or denied to the elderly solely on the basis of their "chronological age", without considering the patient's true "biological age".

Beyond adding years to life: health-related quality-of-life and functional outcomes in patients with severe aortic valve stenosis at high surgical risk undergoing transcatheter aortic valve replacement

Aortic valve stenosis (AVS) is the most frequent acquired valvular heart disease in western industrialized countries and its prevalence considerably increases with age. Once becoming symptomatic severe AVS has a very poor prognosis. Progressive and rapid symptom deterioration leads to an impairment of functional status and compromised healthrelated quality-of-life (HrQoL) simultaneously. Until recently, surgical aortic valve replacement (SAVR) has been the only effective treatment option for improving symptoms and prolonging survival. Transcatheter aortic valve replacement (TAVR) emerged as an alternative treatment modality for those patients with severe symptomatic AVS in whom the risk for SAVR is considered prohibitive or too high. TAVR has gained clinical acceptance with almost startling rapidity and has even quickly become the standard of care for the treatment of appropriately selected individuals with inoperable AVS during recent years. Typically, patients currently referred for and treated by TAVR are elderly with a concomitant variable spectrum of multiple comorbidities, disabilities and limited life expectancy. Beyond mortality and morbidity, the assessment of HrQoL is of paramount importance not only to guide patient-centered clinical decision-making but also to judge this new treatment modality. As per current evidence, TAVR significantly improves HrQoL in high-surgical risk patients with severe AVS with sustained effects up to two years when compared with optimal medical care and demonstrates comparable benefits relative to SAVR.

Along with a provision of a detailed overview of the current literature regarding functional and HrQoL outcomes in patients undergoing TAVR, this review article addresses specific considerations of the HrQoL aspect in the elderly patient and finally outlines the implications of HrQoL outcomes for medico-economic deliberations.

The silent and apparent neurological injury in transcatheter aortic valve implantation study (SANITY): concept, design and rationale

Background

The incidence of clinically apparent stroke in transcatheter aortic valve implantation (TAVI) exceeds that of any other procedure performed by interventional cardiologists and, in the index admission, occurs more than twice as frequently with TAVI than with surgical aortic valve replacement (SAVR). However, this represents only a small component of the vast burden of neurological injury that occurs during TAVI, with recent evidence suggesting that many strokes are clinically silent or only subtly apparent. Additionally, insult may manifest as slight neurocognitive dysfunction rather than overt neurological deficits. Characterisation of the incidence and underlying aetiology of these neurological events may lead to identification of currently unrecognised neuroprotective strategies.

Methods

The Silent and Apparent Neurological Injury in TAVI (SANITY) Study is a prospective, multicentre, observational study comparing the incidence of neurological injury after TAVI versus SAVR. It introduces an intensive, standardised, formal neurologic and neurocognitive disease assessment for all aortic valve recipients, regardless of intervention (SAVR, TAVI), valve-type (bioprosthetic, Edwards SAPIEN-XT) or access route (sternotomy, transfemoral, transapical or transaortic). Comprehensive monitoring of neurological insult will also be recorded to more fully define and compare the neurological burden of the procedures and identify targets for harm minimisation strategies.

Discussion

The SANITY study undertakes the most rigorous assessment of neurological injury reported in the literature to date. It attempts to accurately characterise the insult and sustained injury associated with both TAVI and SAVR in an attempt to advance understanding of this complication and associations thus allowing for improved patient selection and procedural modification.