Outcomes and cost of cardiac surgery in octogenarians is related to type of operation: a multiinstitutional analysis

Clinical Outcomes after Multivalve Surgery in Octogenarians: Evaluating the Need for a Paradigm Shift

(1) Background: this study addresses the lack of comprehensive research on outcomes in octogenarians undergoing cardiac surgery for multivalvular disease, emphasizing the need for a critical examination of the intervention's overall worth in this aging population. (2) Methods: By analyzing short-term and mid-term data from 101 consecutive octogenarian patients undergoing multivalve surgery, the study identifies predictors for in-hospital and one-year mortality. (3) Results: In-hospital mortality increased fourfold with the occurrence of at least one postoperative complication. Octogenarians undergoing multivalve surgery experienced an in-hospital mortality rate of 13.9% and an overall one-year mortality rate of 43.8%. Postoperative delirium was identified as an independent risk factor, contributing to elevated risks of both in-hospital and one-year mortality. Prolonged surgical procedure time emerged as an independent risk factor associated with increased in-hospital mortality. Continuous veno-venous hemodialysis showed an independent impact on in-hospital mortality. Both re-intubation and the transfusion of packed red blood cells were identified as independent risk factors for one-year mortality. (4) Conclusions: This study urges a critical examination of the justification for multivalve surgeries in high-risk elderly patients, emphasizing a paradigm shift. It advocates for interdisciplinary collaboration and innovative strategies, such as staged hybrid procedures, to improve therapeutic approaches for this challenging patient group to achieve a better therapeutic outcome for these patients.

Identifying risk factors for perioperative decline in right ventricular performance in cardiac surgery patients: a prospective observational study in a tertiary care hospital

OBJECTIVES

Impaired right ventricular (RV) function after cardiac surgery is associated with morbidity and long-term mortality. The purpose of this study was to identify factors that play a role in the development of RV dysfunction in the perioperative cardiac surgery setting.

DESIGN

We performed a prospective, observational, single centre study. Over a 2-year period, baseline and perioperative characteristics were recorded. For analysis, subjects were divided into three groups: patients with a ≥3% absolute increase in postoperative RV ejection fraction (RVEF) in comparison to baseline (RVEF+), patients with a ≥3% absolute decrease in RVEF (RVEF-) and patients with a <3% absolute change in RVEF (RVEF=).

SETTING

Tertiary care hospital in the Netherlands.

PARTICIPANTS

We included all cardiac surgery patients ≥18 years of age equipped with a pulmonary artery catheter and admitted to the ICU in 2015-2016. There were no exclusion criteria. A total number of 267 patients were included (65.5% men).

OUTCOME MEASURES

Risk factors for a perioperative decline in RV function.

RESULTS

A reduction in RVEF was observed in 40% of patients. In multivariate analysis, patients with RVEF- were compared with patients with RVEF= (first-mentioned OR) and RVEF+ (second-mentioned OR). Preoperative use of calcium channel blocker (CCB) (OR 3.06, 95% CI 1.24 to 7.54/OR 2.73, 95% CI 1.21 to 6.16 (both p=0.015)), intraoperative fluid balance (FB) (OR 1.45, 95% CI 1.02 to 2.06 (p=0.039)/OR 1.09, 95% CI 0.80 to 1.49 (p=0.575)) and baseline RVEF (OR 1.22; 95% CI 1.14 to 1.30/OR 1.27, 95% CI 1.19 to 1.35 (both p<0.001)) were identified as independent risk factors for a decline in RVEF during surgery.

CONCLUSION

Apart from the impact of the perioperative FB, preoperative use of a CCB as a risk factor for perioperative reduction in RVEF is the most prominent new finding of this study.

Impact of comorbidities on older patients undergoing open heart surgery

BACKGROUND

The number of elderly patients undergoing cardiac surgery is increasing. Age greater than 80 years has been identified as a strong independent risk factor for shortand long-term survival. The current study is aimed to identify the impact of preoperative comorbidities on early and late outcomes in older patients undergoing cardiac surgery.

METHODS

Baseline characteristics, procedurals and postoperative complications of all patients undergoing cardiac surgery at our institution are collected. The current analysis is focused on patients aged at least 80 years at the time of intervention and treated from January 2010 to December 2019.

RESULTS

In-hospital mortality resulted as 6.3%. Redo intervention [odds ratio (OR) 2.49, 95% confidence interval (CI) 1.13-5.48], chronic obstructive pulmonary disease (COPD) (OR 2.99, 95% CI 1.75-5.12) and peripheral arterial disease (PAD) (OR 2.23, 95% CI 1.30-3.81) were independent baseline predictors of outcome in the multivariate analysis. Prolonged extracorporeal circulation time, need for transfusion and prolonged intubation time strongly and independently predicted in-hospital mortality. During a mean follow-up of 3.6 years 34.3% of patients died and unplanned admission (HR 1.33, 95% CI 1.05-1.67), NYHA class III-IV (HR 1.35, 95% CI 1.12-1.64), diabetes (HR 1.27, 95% CI 1.01-1.59), COPD (HR 1.60, 95% CI 1.25-2.04) and PAD (HR 1.32, 95% CI 1.03-1.71) resulted as independent predictors of all-cause death.

CONCLUSION

Cardiac surgery is feasible in octogenarians, with an acceptable risk of mortality. Chronological age itself should not be the main determinant of choice while referring patients for cardiac surgical intervention. Comorbidities such as COPD, PAD and diabetes need to be taken into account for risk stratification.

Changing clinical profiles and in-hospital outcomes of octogenarians undergoing cardiac surgery over 18 years: a single-centre experience†

OBJECTIVES

With an ageing population, increasing numbers of octogenarians are undergoing high-risk cardiac surgery. We examine the changing characteristics and in-hospital outcomes for octogenarians over an 18-year period.

METHODS

Clinical data from our prospective database for all octogenarians who had cardiac surgery from March 1999 through May 2016 were reviewed. We examined trends, risk profiles and in-hospital outcomes over 3 eras, namely early (1999-2004), middle (2005-2010) and late (2011-2016). A multivariable analysis was performed to identify independent predictors for adverse outcomes.

RESULTS

There were 1022 patients aged 80-94 years in our study cohort. The octogenarian population increased progressively from early to late eras (4.5%, n = 255 vs 7.1%, n = 321 vs 9.3%, n = 446), as the average logistic EuroSCORE predicted mortality (9% vs 9.7% vs 10.1%, P < 0.01). On the contrary, observed mortality declined substantially (9.4% vs 7.8% vs 4.7%, P = 0.04) over this period. While cardiac morbidity and respiratory comorbidities were more prevalent in the late era, chronic renal failure was more frequent in the early era. Over time, more procedures were performed electively (P = 0.05). Common operations across all eras were coronary artery bypass grafting (CABG), aortic valve replacement and CABG + aortic valve replacement. Emergency operation [odds ratio (OR) 4.96, 95% confidence interval (CI) 1.51-16.35; P < 0.01], poor ejection fraction (OR 3.38, 95% CI 1.80-6.32; P < 0.01) and bypass time (OR 1.01, 95% CI 1.00-1.02; P < 0.01) were predictors of in-hospital mortality. The late era of surgery (OR 0.41, 95% CI 0.23-0.73; P < 0.01) was associated with reduced mortality risk.

CONCLUSIONS

The operative outcome in this growing surgical population is steadily improving despite the increasing prevalence of comorbidities, and surgery should be performed electively as much as possible.

Clinical, sonographic characteristics and long-term prognosis of valvular heart disease in elderly patients

Background

Valvular heart disease (VHD) is expected to become more prevail as the population ages and disproportionately affects older adults. However, direct comparison of clinical characteristics, sonographic diagnosis, and outcomes in VHD patients aged over 65 years is scarce. The objective of this study was to evaluate the differences in clinical characteristics and prognosis in two age-groups of geriatric patients with VHD.

Methods

We retrospectively enrolled consecutive individuals aged ≥ 65 years from Guangdong Provincial People's Hospital and screened for VHD using transthoracic echocardiography (TTE) or transesophageal echocardiography (TEE). Finally, 260 (48.9%) patients were in the 65-74 years group, and 272 (51.1%) were in the ≥ 75-year group. Factors that affected long-term survival was explored. A multivariable Cox hazards regression was performed to identify the predictors of major adverse cardiac events (MACEs) in each group.

Results

In our population, the older group were more likely to have chronic obstructive pulmonary disease (COPD), degenerative VHD, but with less rheumatic VHD, aortic stenosis (AS) and mitral stenosis (MS). Compared with those aged 65-74 years, the older group had a higher incidence of all-cause death (10.0% vs. 16.5%, P = 0.027), ischemic stroke (13.5% vs. 20.2%, P = 0.038) and MACEs (37.3% vs. 48.2%, P = 0.011) at long-term follow-up. In multivariable Cox regression analysis, mitral regurgitation, a history of COPD, chronic kidney disease, diabetes, hypertension, atrial fibrillation and New York Heart Association (NYHA) functional class were identified as independent predictors of MACEs in the older group.

Conclusion

Advanced age profoundly affect prognosis and different predictors were associated with MACEs in geriatric patients with VHD.

Impaired right ventricular ejection fraction after cardiac surgery is associated with a complicated ICU stay

Background

Right ventricular (RV) dysfunction is a known risk factor for increased mortality in cardiac surgery. However, the association between RV performance and ICU morbidity is largely unknown.

Methods

We performed a single-centre, retrospective study including cardiac surgery patients equipped with a pulmonary artery catheter, enabling continuous right ventricular ejection fraction (RVEF) measurements. Primary endpoint of our study was ICU morbidity (as determined by ICU length of stay, duration of mechanical ventilation, usage of inotropic drugs and fluids, and kidney dysfunction) in relation to RVEF. Patients were divided into three groups according to their RVEF; < 20%, 20-30%, and > 30%.

Results

We included 1109 patients. Patients with a RVEF < 20% had a significantly longer stay in ICU, a longer duration of mechanical ventilation, higher fluid balance, a higher incidence of inotropic drug usage, and more increase in postoperative creatinine levels in comparison to the other subgroups. In a multivariate analysis, RVEF was independently associated with increased ICU length of stay (OR 0.934 CI 0.908-0.961, p < 0.001), prolonged duration of mechanical ventilation (OR 0.969, CI 0.942-0.998, p = 0.033), usage of inotropic drugs (OR 0.944, CI 0.917-0.971, p < 0.001), and increase in creatinine (OR 0.962, CI 0.934-0.991, p = 0.011).

Conclusions

A decreased RVEF is independently associated with a complicated ICU stay.

Trends in mortality and major complications for patients undergoing coronary artery bypass grafting among Urban Teaching Hospitals in China: 2004 to 2013

Aims

Although the number of hospitals performing cardiac surgery has increased rapidly in China, information regarding the trends in coronary artery bypass grafting (CABG) outcomes remains unknown.

Methods and results

We used data from the Chinese Cardiac Surgery Registry, the largest registry system that accounts for nearly 50% of total annual CABG volume in China, to assess trends of in-hospital mortality and major complication rates for patients receiving isolated CABG in 102 urban teaching hospitals in China from 25 January 2004 through 31 December 2013 (except 2006 and 2009). Using a mixed effects model, we estimated annual trends in each of these two outcomes overall and by age groups (18-64 and 65 years or older), adjusted for patient characteristics. We also assessed the trends in pre-operative, post-operative, and total length of stay (LOS). The study included 40 652 patients across 102 hospitals. Between 2004 and 2013, patients' mean age decreased from 62.7 to 61.4 years, in-hospital mortality decreased from 2.8% to 1.6% (difference, 1.3%, 95% CI: 0.70-1.85), and major complication rates decreased from 7.8% to 3.8% (difference, 4.0%; 95% CI: 3.05-4.90). The reduction in mortality and major complication rates were consistent across age groups. Between 2004 and 2013, the median (inter-quartile range) pre-operative LOS remained unchanged, post-operative LOS declined from 12.0 (8.0) to 10.0 (7.0) days, and total LOS declined from 22.0 (13.0) to 20.0 (12.0) days.

Conclusion

Isolated CABG-related in-hospital mortality, major complication rates, and LOS have improved in urban teaching hospitals in China over the last decade.

Outcomes and Predictors of Mortality After Mitral Valve Surgery in High-Risk Elderly Patients: The Heidelberg Experience

Background

Overall, life expectancy at the age of 80 has significantly increased in the industrialized world and the proportion of this age class undergoing cardiac surgery has also grown. In this context, we have analyzed a contemporary series of octogenarians undergoing mitral valve surgery at our institution.

Material/Methods

We performed a retrospective analysis of 138 consecutive octogenarians receiving mitral valve surgery between January 2006 and April 2017. Preoperative comorbidities, early mortality, postoperative clinical course, and predictors of mortality were examined.

Results

The mean age was 82.4±2.0 years and 50% (n=69) were male. Preoperative comorbidities included history of heart infarction (24.6%, n=34), chronic renal failure (37.7%, n=52), and COPD (27.5%, n=38). A total of 52.9% (n=73) had a history of previous cardiac decompensation, while 20 (14.5%) presented with cardiogenic shock or cardiac arrest. In all, 33 patients (23.9%) underwent emergency surgery. There were only 39 isolated mitral valve procedures, while 99 patients (71.7%) underwent various concomitant procedures. The intensive care unit average length of stay was 5.3±7.5 days. Respiratory complications and sepsis were the most frequent postoperative complications. Emergency surgery and concomitant coronary artery bypass grafting were the most important predictors of early mortality. The overall 30-day mortality was 18.1% (n=25). The mean follow-up time was 1.7±2.3 years.

Conclusions

Octogenarians are increasingly represented in cardiac surgery and combined procedures. Prudent patient selection is necessary for optimizing postoperative outcomes among the elderly. In our seriously ill octogenarian cohort, mitral valve surgery was associated with moderate but acceptable mid-term survival.

Isolated and Combined Valve Surgery in Elderly Patients: A Comparison of Mid-Term Results

BACKGROUND

This study examined mid-term outcomes of valve surgery in the elderly, and focused on the difference in outcomes between isolated and combined valve surgery.

METHODS

From January 2012 to June 2016, 113 consecutive patients aged 75 years and older underwent valve surgery. In all, 60 underwent isolated valve surgery (Group I), and 53 underwent combined valve surgery (Group C) involving the combination of any valve procedures or valve surgery with concurrent other procedure. Short- and mid-term outcomes were compared between the two groups.

RESULTS

There was no significant difference in length of intensive care unit stay (2.8 days in Group S vs. 4.2 days in Group C, p = 0.08), hospital stay (16.2 vs. 18.7 days, p = 0.22), and mechanical ventilation (11.2 vs. 15.0 hours, p = 0.28). Neither was there any significant difference in operative mortality (1.6% vs. 5.6%, p = 0.25) nor morbidity (8.3% vs. 9.4%, p = 0.83) between the two groups. Actuarial survival rates at 1 and 3 years were 98.3% in Group S and 92.0% in Group C (log-rank p = 0.126).

CONCLUSION

Once patients have tolerated combined surgery during the early postoperative period, good survival rates equaling those of isolated valve surgery can be expected.

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.

Exercise-based cardiac rehabilitation after heart valve surgery: cost analysis of healthcare use and sick leave

Background

Owing to a lack of evidence, patients undergoing heart valve surgery have been offered exercise-based cardiac rehabilitation (CR) since 2009 based on recommendations for patients with ischaemic heart disease in Denmark. The aim of this study was to investigate the impact of CR on the costs of healthcare use and sick leave among heart valve surgery patients over 12 months post surgery.

Methods

We conducted a nationwide survey on the CR participation of all patients having undergone valve surgery between 1 January 2011 and 30 June 2011 (n=667). Among the responders (n=500, 75%), the resource use categories of primary and secondary healthcare, prescription medication and sick leave were analysed for CR participants (n=277) and non-participants (n=223) over 12 months. A difference-in-difference analysis was undertaken. All estimates were presented as the means per patient (95% CI) based on non-parametric bootstrapping of SEs.

Results

Total costs during the 12 months following surgery were €16 065 per patient (95% CI 13 730 to 18 399) in the CR group and €15 182 (12 695 to 17 670) in the non-CR group. CR led to 5.6 (2.9 to 8.3, p<0.01) more outpatient visits per patient. No statistically significant differences in other cost categories or total costs €1330 (−4427 to 7086, p=0.65) were found between the groups.

Conclusions

CR, as provided in Denmark, can be considered cost neutral. CR is associated with more outpatient visits, but CR participation potentially offsets more expensive outpatient visits. Further studies should investigate the benefits of CR to heart valve surgery patients as part of a formal cost-utility analysis.

Cardiac surgery costs according to the preoperative risk in the Brazilian public health system

BACKGROUND

Heart surgery has developed with increasing patient complexity.

OBJECTIVE

To assess the use of resources and real costs stratified by risk factors of patients submitted to surgical cardiac procedures and to compare them with the values reimbursed by the Brazilian Unified Health System (SUS).

METHOD

All cardiac surgery procedures performed between January and July 2013 in a tertiary referral center were analyzed. Demographic and clinical data allowed the calculation of the value reimbursed by the Brazilian SUS. Patients were stratified as low, intermediate and high-risk categories according to the EuroSCORE. Clinical outcomes, use of resources and costs (real costs versus SUS) were compared between established risk groups.

RESULTS

Postoperative mortality rates of low, intermediate and high-risk EuroSCORE risk strata showed a significant linear positive correlation (EuroSCORE: 3.8%, 10%, and 25%; p < 0.0001), as well as occurrence of any postoperative complication EuroSCORE: 13.7%, 20.7%, and 30.8%, respectively; p = 0.006). Accordingly, length-of-stay increased from 20.9 days to 24.8 and 29.2 days (p < 0.001). The real cost was parallel to increased resource use according to EuroSCORE risk strata (R$ 27.116,00 ± R$ 13.928,00 versus R$ 34.854,00 ± R$ 27.814,00 versus R$ 43.234,00 ± R$ 26.009,00, respectively; p < 0.001). SUS reimbursement also increased (R$ 14.306,00 ± R$ 4.571,00 versus R$ 16.217,00 ± R$ 7.298,00 versus R$ 19.548,00 ± R$935,00; p < 0.001). However, as the EuroSCORE increased, there was significant difference (p < 0.0001) between the real cost increasing slope and the SUS reimbursement elevation per EuroSCORE risk strata.

CONCLUSION

Higher EuroSCORE was related to higher postoperative mortality, complications, length of stay, and costs. Although SUS reimbursement increased according to risk, it was not proportional to real costs.

Age-dependent trends in postoperative mortality and preoperative comorbidity in isolated coronary artery bypass surgery: a nationwide study

OBJECTIVES

An increasing number of octogenarians are being subjected to coronary artery bypass grafting (CABG). The purpose of this study was to examine age-dependent trends in postoperative mortality and preoperative comorbidity over time following CABG.

METHODS

All patients who underwent isolated CABG surgery between January 1996 and December 2012 in Denmark were included. Patients were identified through nationwide administrative registers. Age was categorized into five different groups and time into three periods to see if mortality and preoperative comorbidity had changed over time. Predictors of 30-day mortality were analysed in a multivariable Cox proportional-hazard models and survival at 1 and 5 years was estimated by Kaplan-Meier curves.

RESULTS

A total of 38 830 patients were included; the median age was 65.4 ± 9.5 years, increasing over time to 66.6 ± 9.5 years. Males comprised 80%. The number of octogenarians was 1488 (4%). The median survival was 14.7 years (60-69 years), 10.7 years (70-74 years), 8.9 years (75-79 years) and 7.2 years (≥80 years). The 30-day mortality rate was 3%, increasing with age (1% in patients <60 years, 8% in octogenarians). The long-term mortality rate at 1 and 5 years was 2 and 7% (age <60 years) and 14 and 36% (age >80 years), respectively. The proportion of patients >75 years increased from 10 to 20% during the study period as well as the proportion of patients undergoing urgent or emergency surgery. The burden of comorbidities increased over time, e.g. congestive heart failure 13-17%, diabetes 12-21%, stroke 9-11%, in all age groups. Age and emergency surgery were the main predictors of 30-day mortality: age >80 years [hazard ratio (HR): 5.75, 95% confidence interval (CI): 4.41-7.50], emergency surgery (HR: 5.23, 95% CI: 4.38-6.25).

CONCLUSION

Patients are getting older at the time of surgery and have a heavier burden of comorbidities than before. The proportion of patients undergoing urgent or emergency surgery increased with age and over time. Despite this, the 30-day mortality decreased over time and long-term survival increased, except in octogenarians where it was stable. Octogenarians had substantially higher 30-day mortality compared with younger patients but surgery can be performed with acceptable risks and good long-term outcomes.

A systematic review and meta-analysis of surgical outcomes following mitral valve surgery in octogenarians: implications for transcatheter mitral valve interventions

AIMS

To evaluate the outcomes of mitral valve surgery in octogenarians with severe symptomatic mitral regurgitation (MR).

METHODS AND RESULTS

We performed a systematic review and meta-analysis of data on octogenarians who underwent mitral valve replacement (MVR) or mitral valve repair (MVRpr). Our search yielded 16 retrospective studies. Using Bayesian hierarchical models, we estimated the pooled proportion of 30-day mortality, postoperative stroke, and long-term survival. The pooled proportion of 30-day postoperative mortality was 13% following MVR (10 studies, 3,105 patients, 95% credible interval [CI] 9-18%), and 7% following MVRpr (six studies, 2,642 patients, 95% CI: 3-12%). Furthermore, pooled proportions of postoperative stroke were 4% (six studies, 2,945 patients, 95% CI: 3-7%) and 3% (three studies, 348 patients, 95% CI: 1-8%) for patients undergoing MVR and MVRpr, respectively. Pooled survival rates at one and five years following MVR (four studies, 250 patients) were 67% (95% CI: 50-80%) and 29% (95% CI: 16-47%), and following MVRpr (three studies, 333 patients) were 69% (95% CI: 50-83%) and 23% (95% CI: 12-39%), respectively.

CONCLUSIONS

Surgical treatment of MR in octogenarians is associated with high perioperative mortality and poor long-term survival with an uncertain benefit on quality of life. These data highlight the importance of patient selection for operative intervention and suggest that future transcatheter mitral valve therapies such as transcatheter mitral valve repair (TMVr) and/or transcatheter mitral valve implantation (TMVI), may provide an alternative therapeutic approach in selected high-risk elderly patients.

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.

The changing face of cardiac surgery: practice patterns and outcomes 2001-2010

BACKGROUND

Advances in cardiac surgical care have allowed for successful surgery in high-risk elderly patients. Advances in percutaneous coronary intervention (PCI) techniques and expanded indications for PCI have resulted in a decrease in referrals for coronary artery bypass grafting (CABG). Our objective was to document changes in practice patterns and outcomes in a single tertiary cardiac surgery centre serving a large geographic area.

METHODS

For all cardiac surgery cases performed from 2001-2010 we examined its use, patient clinical characteristics, and outcomes. Frailty was assessed using a measure we have previously demonstrated to be associated with adverse outcomes.

RESULTS

During the study period, annual case volume decreased by 13%. The number of isolated CABG cases declined, and valve surgery and other complex procedures increased. The proportion of patients aged ≥ 80 years rose from 7%-12%, and the proportion of frail patients increased from 4%-10%. Although unadjusted in-hospital mortality remained relatively unchanged, intensive care unit (ICU) stays and prolonged institutional care increased. Older age and frailty were associated with mortality, prolonged ICU stays, prolonged institutional care, and a composite of mortality and major morbidities.

CONCLUSIONS

Our findings showed a decline in CABG, an increase in more complex operations, and an increase in prolonged ICU stays and prolonged institutional care. The proportion of frail and elderly patients increased over time and these patient groups were at higher risk of adverse postoperative outcomes. Particular attention is required in the decision for surgery and perioperative management of these patients.

Pooled estimates of immediate and late outcome of mitral valve surgery in octogenarians: a meta-analysis and meta-regression

OBJECTIVE

The authors evaluated the outcome of patients≥80 years undergoing mitral valve (MV) surgery.

DESIGN

Systematic review of the literature and meta-analysis.

SETTING

None.

PARTICIPANTS

None.

INTERVENTIONS

None.

MAIN RESULTS

Twenty-four studies reporting on 5,572 patients ≥80 years of age who underwent MV surgery were included in this analysis. Pooled proportion of operative mortality was 15.0% (95% confidence interval [CI] 11.9-18.1), stroke was 3.9% (95% CI 2.6-5.2), and dialysis was 2.7% (95% CI 0.5-4.9). Early date of study (p = 0.014), increased age (p = 0.006), MV replacement (p = 0.008), procedure other than isolated MV surgery (p = 0.010), MV surgery associated with coronary artery surgery (p = 0.029), aortic cross-clamping time (p<0.001), and cardiopulmonary bypass time (p<0.001) were associated significantly with increased operative mortality. MV repair had lower operative mortality compared with MV replacement (7.3% v 14.2%, relative risk 0.573, 95% CI 0.342-0.962). Random-effects metaregression showed that prolonged aortic cross-clamping time (p = 0.005) was the only determinant of increased operative mortality, even when adjusted (p<0.001) for date of study (p = 0.004). Operative mortality was significantly higher in studies reporting a mean cross-clamp time >90 minutes (17.0% v 7.4%, p<0.001). Survival rates at 1, 3, and 5 years were 76.1%, 67.7%, and 56.5%, respectively.

CONCLUSIONS

MV surgery in patients ≥80 years of age is associated with operative mortality, which has decreased significantly during recent years. Prolonged aortic cross-clamp time is a major determinant of operative mortality. MV repair may achieve better results than MV replacement in the very elderly. Five-year survival of these patients is good and justifies surgical treatment of MV diseases in octogenarians.

Contemporary strategy for aortic valve stenosis in octogenarians

The number of patients with aortic stenosis (AS) has been increasing over recent decades with the longer life expectancy of the general population. AS is life-threatening without surgery and since many elderly patients have a variety of comorbid conditions, 30-40 % of those with severe AS have been denied surgery. However, recent data on standard aortic valve replacement (AVR) for octogenarians have revealed excellent outcomes, with 2.4-6.8 % early mortality and similar survival rates of octogenarians who undergo AVR vs. the general population. The reported incidences of postoperative stroke, dialysis, and pacemaker implantation were 2.4, 2.6, and 4.6 %, respectively. Transcatheter aortic valve replacement (TAVR) is the alternative therapy for patients who are not able to undergo standard AVR and it is developing rapidly. The placement of aortic transcatheter valves (PARTNER) trial showed acceptable early outcomes. The mortality rates from any cause were 3.4 % in the TAVR group and 6.5 % in the AVR group at 30 days, 24.2 and 26.8 % at 1 year, and 33.9 and 35.0 % at 2 years, respectively. Stroke rate was higher in the TAVR group than in the AVR group (3.4 vs. 1.9 %). Vascular complications and paravalvular leakage are frequent procedure-related complications, which must be addressed because they are associated with increased mortality.

Costs for surgical aortic valve replacement according to preoperative risk categories

BACKGROUND

The introduction of transcatheter aortic valve replacement (TAVR) led to more rigorous evaluation of surgical aortic valve replacement (SAVR) as a benchmark for TAVR. However, limited real-life cost data of SAVR are available. Therefore, the purpose of our study was to assess actual costs and resource utilization of SAVR in patients at different operating risk.

METHODS

Study data were drawn from a multi-institutional statewide database comprised of all cardiac surgical procedures in the Commonwealth of Virginia. The study included 2,530 elective, primary, isolated SAVRs performed from 2003 to 2012. Clinical data were matched with universal billing data. Patients were stratified into low-, intermediate- and high-risk categories according to the Society of Thoracic Surgeons- Predicted Risk of Mortality (STS-PROM) score: 0% to 4%, 4% to 8% , and greater than 8%, respectively. Clinical outcomes, resource use, and costs were compared between categories.

RESULTS

With increasing risk, there were higher rates of postoperative mortality (low 1.2% versus intermediate 2.7% versus high 6.2%, p < 0.001) and renal failure (2.7% vs 7.2% vs 10.6%; p < 0.001). The proportion of patients with any postoperative complication was higher with increasing risk (34% vs 48% vs 53%; p < 0.001). Length-of-stay increased from 6.8 days in the low-risk category to 10.2 and 11.3 days in the intermediate- and high-risk category, respectively (p < 0.001). There was an increase in mean total costs from the low- (n = 2,002) to intermediate- (n = 415) to high-risk (n = 113) category ($35,021 ± $22,642 vs $46,101 ± $42,460 vs $51,145 ± $31,655; p < 0.001).

CONCLUSIONS

Higher STS-PROM was significantly associated with higher postoperative mortality, complications, length-of-stay, and costs. The SAVR cost data provide a basis for the analysis of TAVR cost-effectiveness and its impact on payment systems.

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

OBJECTIVE

This study was planned to evaluate the outcome of patients ≥80 years old undergoing isolated conventional aortic valve replacement (AVR).

METHODS

Systematic review of the literature and meta-analysis of data on octogenarians and nonagenarians who underwent isolated AVR were performed.

RESULTS

The literature search yielded 48 observational studies reporting on 13 216 patients ≥80 years old. Pooled proportion of immediate postoperative mortality was 6.7 % (95% CI 5.8-7.5, 47 studies, 13,092 patients), and it was 5.8% (95% CI 4.8-6.9) in 18 studies with a mid-date from 2000 to 2006 and 7.5% (95% CI 6.8-8.2) in 30 studies with a mid-date from 1982 to 1999 (P = .004). Pooled proportion of postoperative stroke was 2.4% (95% CI 2.1-2.7, 21 studies, 8,436 patients), that of postoperative dialysis was 2.6% (95% CI 1.6-3.8, 10 studies, 1,945 patients), and that of postoperative implantation of a pacemaker was 4.6% (95% CI 3.6-5.8, 6 studies, 1,470 patients). Pooled survival rates at 1, 3, 5, and 10 years after isolated AVR were 87.6%, 78.7%, 65.4%, and 29.7%, respectively.

CONCLUSIONS

Immediate postoperative mortality and morbidity after isolated AVR in patients ≥80 years old are rather low. Postoperatively mortality decreased even further in the most recent series. Importantly, isolated AVR in these high-risk patients was associated with good late survival. These findings suggest that advanced age alone cannot be considered as a contraindication to conventional isolated AVR and that any new valve prosthesis implanted in these patients should be durable enough to guarantee the results so far offered by conventional surgery.