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Ishii M, Taniguchi T, Morimoto T, Ogawa H, Masunaga N, Abe M, Yoshikawa Y, Shiomi H, Ando K, Kanamori N, Murata K, Kitai T, Kawase Y, Izumi C, Miyake M, Mitsuoka H, Kato M, Hirano Y, Matsuda S, Nagao K, Inada T, Mabuchi H, Takeuchi Y, Yamane K, Toyofuku M, Minamino-Muta E, Kato T, Inoko M, Ikeda T, Komasa A, Ishii K, Hotta K, Higashitani N, Kato Y, Inuzuka Y, Jinnai T, Morikami Y, Akao M, Minatoya K, Kimura T. Reasons for Choosing Conservative Management in Symptomatic Patients With Severe Aortic Stenosis - Observations From the CURRENT AS Registry. Circ J 2019; 83:1944-1953. [PMID: 31316039 DOI: 10.1253/circj.cj-19-0247] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND There has not been a previous report on the long-term outcomes of those patients who refuse aortic valve replacement (AVR) despite physicians' recommendations.Methods and Results:Among 3,815 consecutive patients with severe aortic stenosis (AS) enrolled in the CURRENT AS registry, the study population comprised 2,005 symptomatic patients, who were subdivided into 3 groups by their treatment strategy and the reasons for conservative strategy (Initial AVR group: n=905; Patient rejection group: n=256; Physician judgment group, n=844). The primary outcome measure was a composite of aortic valve-related death and heart failure hospitalization. Patients in the patient rejection group as compared with those in the physician judgment group were younger, and had less comorbidities, and lower surgical risk scores. The cumulative 5-year incidence of the primary outcome measure in the patient rejection group was markedly higher than that in the initial AVR group, and was similar to that in the physician judgment group (60.7%, 19.0%, and 66.4%, respectively). CONCLUSIONS Patient rejection was the reason for non-referral to AVR in nearly one-quarter of the symptomatic patients with severe AS who were managed conservatively. The dismal outcome in patients who refused AVR was similar to that in patients who were not referred to AVR based on physician judgment despite less comorbidities and lower surgical risk scores in the former than in the latter.
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Affiliation(s)
- Mitsuru Ishii
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Tomohiko Taniguchi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | | | - Hisashi Ogawa
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Nobutoyo Masunaga
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Mitsuru Abe
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Yusuke Yoshikawa
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital
| | | | | | - Takeshi Kitai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Yuichi Kawase
- Department of Cardiovascular Medicine, Kurashiki Central Hospital
| | | | | | - Hirokazu Mitsuoka
- Division of Cardiology, Nara Hospital, Kinki University Faculty of Medicine
| | - Masashi Kato
- Department of Cardiology, Mitsubishi Kyoto Hospital
| | - Yutaka Hirano
- Department of Cardiology, Kindai University Hospital
| | - Shintaro Matsuda
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Kazuya Nagao
- Department of Cardiovascular Center, Osaka Red Cross Hospital
| | - Tsukasa Inada
- Department of Cardiovascular Center, Osaka Red Cross Hospital
| | | | | | | | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center
| | - Eri Minamino-Muta
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Takao Kato
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Moriaki Inoko
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital
| | | | - Akihiro Komasa
- Department of Cardiology, Kansai Electric Power Hospital
| | | | - Kozo Hotta
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | | | | | | | | | | | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
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Martínez-Sellés M, Gómez Doblas JJ, Carro Hevia A, García de la Villa B, Ferreira-González I, Alonso Tello A, Andión Ogando R, Ripoll Vera T, Arribas Jiménez A, Carrillo P, Rodríguez Pascual C, Casares i Romeva M, Borras X, Cornide L, López-Palop R. Prospective registry of symptomatic severe aortic stenosis in octogenarians: a need for intervention. J Intern Med 2014; 275:608-20. [PMID: 24320176 DOI: 10.1111/joim.12174] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To study the factors associated with choice of therapy and prognosis in octogenarians with severe symptomatic aortic stenosis (AS). STUDY DESIGN Prospective, observational, multicenter registry. Centralized follow-up included survival status and, if possible, mode of death and Katz index. SETTING Transnational registry in Spain. SUBJECTS We included 928 patients aged ≥80 years with severe symptomatic AS. INTERVENTIONS Aortic-valve replacement (AVR), transcatheter aortic-valve implantation (TAVI) or conservative therapy. MAIN OUTCOME MEASURES All-cause death. RESULTS Mean age was 84.2 ± 3.5 years, and only 49.0% were independent (Katz index A). The most frequent planned management was conservative therapy in 423 (46%) patients, followed by TAVI in 261 (28%) and AVR in 244 (26%). The main reason against recommending AVR in 684 patients was high surgical risk [322 (47.1%)], other medical motives [193 (28.2%)], patient refusal [134 (19.6%)] and family refusal in the case of incompetent patients [35 (5.1%)]. The mean time from treatment decision to AVR was 4.8 ± 4.6 months and to TAVI 2.1 ± 3.2 months, P < 0.001. During follow-up (11.2-38.9 months), 357 patients (38.5%) died. Survival rates at 6, 12, 18 and 24 months were 81.8%, 72.6%, 64.1% and 57.3%, respectively. Planned intervention, adjusted for multiple propensity score, was associated with lower mortality when compared with planned conservative treatment: TAVI Hazard ratio (HR) 0.68 (95% confidence interval [CI] 0.49-0.93; P = 0.016) and AVR HR 0.56 (95% CI 0.39-0.8; P = 0.002). CONCLUSION Octogenarians with symptomatic severe AS are frequently managed conservatively. Planned conservative management is associated with a poor prognosis.
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Affiliation(s)
- M Martínez-Sellés
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón y Universidad Europea de Madrid, Madrid, Spain
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Nwaejike N, Breen N, Bonde P, Campalani G. Long term results and functional outcomes following cardiac surgery in octogenarians. Aging Male 2009; 12:54-7. [PMID: 19572233 DOI: 10.1080/13685530903033224] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE Cardiac surgery for patients >80 years has seen a dramatic increase in the last decade. The aim was to assess the long term survival and quality of life in this patient population. METHOD Patients who underwent cardiac surgery between 1995 and 2007 were identified and case notes reviewed. Follow-up was undertaken by personal interview with the patient or the nearest kin to complete a pre-planned questionnaire. RESULTS Sixty six (M:F; 45:21) octogenarians had Coronary artery bypass grafting (CABG) only (55%), Aortic valve replacement (AVR) only (12%), Mitral valve replacement (MVR) only (3%), Valve and CABG (25%) and complex procedures (5%). Fifty-eight percent were elective procedures. Operative mortality was 8% (n = 5). Multivariate analysis identified complex procedures, prolonged bypass time and re-do/emergency surgery as predictors of death (p < 0.05). Median Intensive care unit (ICU) stay was 206 h (range 43-1176 h), with >70% leaving ICU in 72 h. Late mortality involved five patients (8%) who died at 10 yr; 7 yr; 3 yr; 1 yr; and 8 months; and 2 yr and 7 months, respectively. Survival by Kaplan-Meir was 8.8 yr (Standard Error (SE) = 0.66, Confidence interval (CI) 7.6-10.1), median survival was 10 yr and mean Barthel's index 17.7 (min 0, max 20). CONCLUSIONS Cardiac surgery can be accomplished in octogenarians with good long-term survival and quality of life. However, complex procedures, prolonged bypass and re-do/emergency surgery contribute significantly to mortality.
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Affiliation(s)
- Nnamdi Nwaejike
- Department of Vascular and Endovascular Surgery, The Royal London Hospital, Barts and the London NHS Trust, London, UK
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Gulbins H, Malkoc A, Ennker J. Combined cardiac surgical procedures in octogenarians: operative outcome. Clin Res Cardiol 2008; 97:176-80. [PMID: 18193375 DOI: 10.1007/s00392-007-0615-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2007] [Accepted: 10/17/2007] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The number of patients with an indication for cardiac surgery in their ninth decade of life is increasing. This study analyses the single-center results with combined and redo cardiac surgical procedures in octogenarians retrospectively. PATIENTS AND METHODS Three groups were evaluated: (I) Two hundred and thirty six patients with combined cardiac surgical procedures, mean age 83.1 +/- 2.5 years, 107 male (129 female). Combined aortic valve replacement (AVR) and aorto coronary bypass (ACB) was done in 215, double valve replacement (DVR) in 21. (II) AVR + ACB-group: 215 patients out of group I. (III) Control group consisting of 124 patients with a mean age of 74.1 +/- 2.8 years (range 70-79.9 years) who received combined AVR and ACB. Risk stratification was done using the additive and logistic Euro-score; values are given as mean +/- standard deviation and were compared using either the t-test or the Chi-square test. RESULTS The observed mortality in group I was 9.3%. Re-intubation was observed in 10.2% and was one major risk factor for in-hospital mortality. As second risk factor, DVR could be identified. 14.8% required hemodialysis postoperatively, but this affected only the length of stay on intensive care unit (ICU) but not mortality. When comparing group II with group III, mortality was higher (10% vs. 4%), the need for hemodialysis was more frequent (16.3% vs. 4.9%), and the incidence of postoperative psycho-syndromes was also higher (26% vs. 8.1%, all: P < 0.05). The duration of ventilation (2.7 +/- 7.7 vs. 1.6 +/- 4.3 days) and the length of stay on ICU (8.2 +/- 8.8 vs. 5.7 +/- 6.4) were longer without reaching statistical significance (P > 0.05). The Euro-score overestimated the real mortality in all groups. CONCLUSIONS Octogenarians requiring combined cardiac surgical procedures required more resources and had a higher in-hospital mortality compared to younger patients. The observed in-hospital mortality was much lower than the predicted justifying the indication for surgical therapy in these patients. Patient selection, however, seems to be important but the Euro-score alone was rather ineffective in predicting poor outcome.
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Affiliation(s)
- H Gulbins
- Department of Cardiac Surgery, Heart Institute Lahr, Lahr, Germany.
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