7
|
Goldberg JB, DeSimone JP, Kramer RS, DiScipio AW, Russo L, Dacey LJ, Leavitt BJ, Helm RE, Baribeau YR, Sardella G, Clough RA, Surgenor SD, Sorensen MJ, Ross CS, Olmstead EM, MacKenzie TA, Malenka DJ, Likosky DS. Impact of Preoperative Left Ventricular Ejection Fraction on Long-Term Survival After Aortic Valve Replacement for Aortic Stenosis. Circ Cardiovasc Qual Outcomes 2013; 6:35-41. [DOI: 10.1161/circoutcomes.112.965772] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The survival of patients who undergo aortic valve replacement (AVR) for severe aortic stenosis with reduced preoperative ejection fractions (EFs) is not well described in the literature.
Methods and Results—
Patients undergoing AVR for severe aortic stenosis were analyzed using the Northern New England Cardiovascular Disease Study Group surgical registry. Patients were stratified by preoperative EF (≥50%, 40%–49%, and <40%) and concomitant coronary artery bypass grafting. Crude and adjusted survival across strata of EF was estimated for patients up to 8 years beyond their index admission. A total of 5277 patients underwent AVR for severe aortic stenosis between 1992 and 2008. There were 727 (14%) patients with preoperative EF <40%. Preoperative EF had minimal effect on postoperative morbidity. There was no difference in 30-day mortality across EF strata among the isolated AVR cohort. Preserved EF conferred 30-day survival benefit among the AVR+coronary artery bypass grafting population (EF≥50%, 96%; EF<40%, 91%;
P
=0.003). Patients with preserved EF had significantly improved 6-month and 8-year survival compared with their reduced EF counterparts.
Conclusions—
Survival after AVR or AVR+coronary artery bypass grafting was most favorable among patients with preoperative preserved EF. However, patients with mild to moderately depressed EF experienced a substantial survival benefit compared with the natural history of medically treated patients. Furthermore, minor reductions of EF carried equivalent increased risk to those with more compromised function suggesting patients are best served when an AVR is performed before even minor reductions in myocardial function.
Collapse
Affiliation(s)
- Joshua B. Goldberg
- From the Departments of Medicine, Surgery, and Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth-Hitchcock Medical Center, Hanover, NH (J.B.G., J.P.D., A.W.D., L.J.D., S.D.S., M.J.S., C.S.R., E.M.O., T.A.M., D.J.M., D.S.L.); Department of Surgery, Maine Medical Center, Portland, ME (R.S.K.); Department of Surgery, Central Maine Medical Center, Lewiston, ME (L.R.); Department of Surgery, Fletcher Allen Health Care, Burlington, VT (B.J.L.)
| | - Joseph P. DeSimone
- From the Departments of Medicine, Surgery, and Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth-Hitchcock Medical Center, Hanover, NH (J.B.G., J.P.D., A.W.D., L.J.D., S.D.S., M.J.S., C.S.R., E.M.O., T.A.M., D.J.M., D.S.L.); Department of Surgery, Maine Medical Center, Portland, ME (R.S.K.); Department of Surgery, Central Maine Medical Center, Lewiston, ME (L.R.); Department of Surgery, Fletcher Allen Health Care, Burlington, VT (B.J.L.)
| | - Robert S. Kramer
- From the Departments of Medicine, Surgery, and Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth-Hitchcock Medical Center, Hanover, NH (J.B.G., J.P.D., A.W.D., L.J.D., S.D.S., M.J.S., C.S.R., E.M.O., T.A.M., D.J.M., D.S.L.); Department of Surgery, Maine Medical Center, Portland, ME (R.S.K.); Department of Surgery, Central Maine Medical Center, Lewiston, ME (L.R.); Department of Surgery, Fletcher Allen Health Care, Burlington, VT (B.J.L.)
| | - Anthony W. DiScipio
- From the Departments of Medicine, Surgery, and Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth-Hitchcock Medical Center, Hanover, NH (J.B.G., J.P.D., A.W.D., L.J.D., S.D.S., M.J.S., C.S.R., E.M.O., T.A.M., D.J.M., D.S.L.); Department of Surgery, Maine Medical Center, Portland, ME (R.S.K.); Department of Surgery, Central Maine Medical Center, Lewiston, ME (L.R.); Department of Surgery, Fletcher Allen Health Care, Burlington, VT (B.J.L.)
| | - Louis Russo
- From the Departments of Medicine, Surgery, and Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth-Hitchcock Medical Center, Hanover, NH (J.B.G., J.P.D., A.W.D., L.J.D., S.D.S., M.J.S., C.S.R., E.M.O., T.A.M., D.J.M., D.S.L.); Department of Surgery, Maine Medical Center, Portland, ME (R.S.K.); Department of Surgery, Central Maine Medical Center, Lewiston, ME (L.R.); Department of Surgery, Fletcher Allen Health Care, Burlington, VT (B.J.L.)
| | - Lawrence J. Dacey
- From the Departments of Medicine, Surgery, and Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth-Hitchcock Medical Center, Hanover, NH (J.B.G., J.P.D., A.W.D., L.J.D., S.D.S., M.J.S., C.S.R., E.M.O., T.A.M., D.J.M., D.S.L.); Department of Surgery, Maine Medical Center, Portland, ME (R.S.K.); Department of Surgery, Central Maine Medical Center, Lewiston, ME (L.R.); Department of Surgery, Fletcher Allen Health Care, Burlington, VT (B.J.L.)
| | - Bruce J. Leavitt
- From the Departments of Medicine, Surgery, and Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth-Hitchcock Medical Center, Hanover, NH (J.B.G., J.P.D., A.W.D., L.J.D., S.D.S., M.J.S., C.S.R., E.M.O., T.A.M., D.J.M., D.S.L.); Department of Surgery, Maine Medical Center, Portland, ME (R.S.K.); Department of Surgery, Central Maine Medical Center, Lewiston, ME (L.R.); Department of Surgery, Fletcher Allen Health Care, Burlington, VT (B.J.L.)
| | - Robert E. Helm
- From the Departments of Medicine, Surgery, and Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth-Hitchcock Medical Center, Hanover, NH (J.B.G., J.P.D., A.W.D., L.J.D., S.D.S., M.J.S., C.S.R., E.M.O., T.A.M., D.J.M., D.S.L.); Department of Surgery, Maine Medical Center, Portland, ME (R.S.K.); Department of Surgery, Central Maine Medical Center, Lewiston, ME (L.R.); Department of Surgery, Fletcher Allen Health Care, Burlington, VT (B.J.L.)
| | - Yvon R. Baribeau
- From the Departments of Medicine, Surgery, and Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth-Hitchcock Medical Center, Hanover, NH (J.B.G., J.P.D., A.W.D., L.J.D., S.D.S., M.J.S., C.S.R., E.M.O., T.A.M., D.J.M., D.S.L.); Department of Surgery, Maine Medical Center, Portland, ME (R.S.K.); Department of Surgery, Central Maine Medical Center, Lewiston, ME (L.R.); Department of Surgery, Fletcher Allen Health Care, Burlington, VT (B.J.L.)
| | - Gerald Sardella
- From the Departments of Medicine, Surgery, and Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth-Hitchcock Medical Center, Hanover, NH (J.B.G., J.P.D., A.W.D., L.J.D., S.D.S., M.J.S., C.S.R., E.M.O., T.A.M., D.J.M., D.S.L.); Department of Surgery, Maine Medical Center, Portland, ME (R.S.K.); Department of Surgery, Central Maine Medical Center, Lewiston, ME (L.R.); Department of Surgery, Fletcher Allen Health Care, Burlington, VT (B.J.L.)
| | - Robert A. Clough
- From the Departments of Medicine, Surgery, and Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth-Hitchcock Medical Center, Hanover, NH (J.B.G., J.P.D., A.W.D., L.J.D., S.D.S., M.J.S., C.S.R., E.M.O., T.A.M., D.J.M., D.S.L.); Department of Surgery, Maine Medical Center, Portland, ME (R.S.K.); Department of Surgery, Central Maine Medical Center, Lewiston, ME (L.R.); Department of Surgery, Fletcher Allen Health Care, Burlington, VT (B.J.L.)
| | - Stephen D. Surgenor
- From the Departments of Medicine, Surgery, and Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth-Hitchcock Medical Center, Hanover, NH (J.B.G., J.P.D., A.W.D., L.J.D., S.D.S., M.J.S., C.S.R., E.M.O., T.A.M., D.J.M., D.S.L.); Department of Surgery, Maine Medical Center, Portland, ME (R.S.K.); Department of Surgery, Central Maine Medical Center, Lewiston, ME (L.R.); Department of Surgery, Fletcher Allen Health Care, Burlington, VT (B.J.L.)
| | - Meredith J. Sorensen
- From the Departments of Medicine, Surgery, and Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth-Hitchcock Medical Center, Hanover, NH (J.B.G., J.P.D., A.W.D., L.J.D., S.D.S., M.J.S., C.S.R., E.M.O., T.A.M., D.J.M., D.S.L.); Department of Surgery, Maine Medical Center, Portland, ME (R.S.K.); Department of Surgery, Central Maine Medical Center, Lewiston, ME (L.R.); Department of Surgery, Fletcher Allen Health Care, Burlington, VT (B.J.L.)
| | - Cathy S. Ross
- From the Departments of Medicine, Surgery, and Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth-Hitchcock Medical Center, Hanover, NH (J.B.G., J.P.D., A.W.D., L.J.D., S.D.S., M.J.S., C.S.R., E.M.O., T.A.M., D.J.M., D.S.L.); Department of Surgery, Maine Medical Center, Portland, ME (R.S.K.); Department of Surgery, Central Maine Medical Center, Lewiston, ME (L.R.); Department of Surgery, Fletcher Allen Health Care, Burlington, VT (B.J.L.)
| | - Elaine M. Olmstead
- From the Departments of Medicine, Surgery, and Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth-Hitchcock Medical Center, Hanover, NH (J.B.G., J.P.D., A.W.D., L.J.D., S.D.S., M.J.S., C.S.R., E.M.O., T.A.M., D.J.M., D.S.L.); Department of Surgery, Maine Medical Center, Portland, ME (R.S.K.); Department of Surgery, Central Maine Medical Center, Lewiston, ME (L.R.); Department of Surgery, Fletcher Allen Health Care, Burlington, VT (B.J.L.)
| | - Todd A. MacKenzie
- From the Departments of Medicine, Surgery, and Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth-Hitchcock Medical Center, Hanover, NH (J.B.G., J.P.D., A.W.D., L.J.D., S.D.S., M.J.S., C.S.R., E.M.O., T.A.M., D.J.M., D.S.L.); Department of Surgery, Maine Medical Center, Portland, ME (R.S.K.); Department of Surgery, Central Maine Medical Center, Lewiston, ME (L.R.); Department of Surgery, Fletcher Allen Health Care, Burlington, VT (B.J.L.)
| | - David J. Malenka
- From the Departments of Medicine, Surgery, and Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth-Hitchcock Medical Center, Hanover, NH (J.B.G., J.P.D., A.W.D., L.J.D., S.D.S., M.J.S., C.S.R., E.M.O., T.A.M., D.J.M., D.S.L.); Department of Surgery, Maine Medical Center, Portland, ME (R.S.K.); Department of Surgery, Central Maine Medical Center, Lewiston, ME (L.R.); Department of Surgery, Fletcher Allen Health Care, Burlington, VT (B.J.L.)
| | - Donald S. Likosky
- From the Departments of Medicine, Surgery, and Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth-Hitchcock Medical Center, Hanover, NH (J.B.G., J.P.D., A.W.D., L.J.D., S.D.S., M.J.S., C.S.R., E.M.O., T.A.M., D.J.M., D.S.L.); Department of Surgery, Maine Medical Center, Portland, ME (R.S.K.); Department of Surgery, Central Maine Medical Center, Lewiston, ME (L.R.); Department of Surgery, Fletcher Allen Health Care, Burlington, VT (B.J.L.)
| | | |
Collapse
|
9
|
Ashikhmina EA, Schaff HV, Dearani JA, Sundt TM, Suri RM, Park SJ, Burkhart HM, Li Z, Daly RC. Aortic Valve Replacement in the Elderly. Circulation 2011; 124:1070-8. [PMID: 21824918 DOI: 10.1161/circulationaha.110.987560] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background—
Few data exist on long-term outcomes of elderly patients after aortic valve replacement. We evaluated latest follow-up information for patients ≥70 years of age after aortic valve replacement.
Methods and Results—
Late overall survival of 2890 consecutive patients ≥70 years of age who underwent aortic valve replacement between January 1993 and December 2007 was reviewed retrospectively, analyzed, and stratified by preoperative and intraoperative variables. Observed 5-, 10-, and 15-year late postoperative survival was lower than generally expected (68%, 34%, and 8% versus 70%, 42%, and 20%, respectively;
P
<0.001). Independent predictors of late death included older age, renal failure, diabetes mellitus, stroke, myocardial infarction, immunosuppression, prior coronary artery bypass grafting, implanted pacemaker, lower ejection fraction, hypertension, and New York Heart Association class III or IV. After stratification by age–comorbidity risk score, 10-year survival for the lowest-risk group (n=946 [33%]) was similar to expected survival (55% versus 55%;
P
=0.50), but for the highest-risk group (n=564 [20%]), survival was significantly lower than expected (9% versus 26%;
P
<0.001). For 229 pairs of propensity-matched patients with mechanical or biological prostheses, survival was not significantly different (67%, 40%, and 19% versus 71%, 45%, and 7% at 5, 10, and 15 years, respectively;
P
=0.81). Structural deterioration of bioprostheses occurred in 64 patients (2.4%).
Conclusions—
Survival of elderly patients after aortic valve replacement is influenced by age and preoperative comorbidities; 33% at lowest risk had overall survival similar to that of an age- and sex-matched general population. There was no sufficient evidence that valve type affected survival. Structural deterioration of aortic bioprostheses was rare.
Collapse
Affiliation(s)
- Elena A. Ashikhmina
- From the Divisions of Cardiovascular Surgery (E.A.A., H.V.S., J.A.D., T.M.S., R.M.S., S.J.P., H.M.B., R.C.D.) and Biomedical Statistics and Informatics (Z.L.), Mayo Clinic, Rochester, MN. Dr Ashikhmina is now with the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Hartzell V. Schaff
- From the Divisions of Cardiovascular Surgery (E.A.A., H.V.S., J.A.D., T.M.S., R.M.S., S.J.P., H.M.B., R.C.D.) and Biomedical Statistics and Informatics (Z.L.), Mayo Clinic, Rochester, MN. Dr Ashikhmina is now with the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Joseph A. Dearani
- From the Divisions of Cardiovascular Surgery (E.A.A., H.V.S., J.A.D., T.M.S., R.M.S., S.J.P., H.M.B., R.C.D.) and Biomedical Statistics and Informatics (Z.L.), Mayo Clinic, Rochester, MN. Dr Ashikhmina is now with the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Thoralf M. Sundt
- From the Divisions of Cardiovascular Surgery (E.A.A., H.V.S., J.A.D., T.M.S., R.M.S., S.J.P., H.M.B., R.C.D.) and Biomedical Statistics and Informatics (Z.L.), Mayo Clinic, Rochester, MN. Dr Ashikhmina is now with the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Rakesh M. Suri
- From the Divisions of Cardiovascular Surgery (E.A.A., H.V.S., J.A.D., T.M.S., R.M.S., S.J.P., H.M.B., R.C.D.) and Biomedical Statistics and Informatics (Z.L.), Mayo Clinic, Rochester, MN. Dr Ashikhmina is now with the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Soon J. Park
- From the Divisions of Cardiovascular Surgery (E.A.A., H.V.S., J.A.D., T.M.S., R.M.S., S.J.P., H.M.B., R.C.D.) and Biomedical Statistics and Informatics (Z.L.), Mayo Clinic, Rochester, MN. Dr Ashikhmina is now with the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Harold M. Burkhart
- From the Divisions of Cardiovascular Surgery (E.A.A., H.V.S., J.A.D., T.M.S., R.M.S., S.J.P., H.M.B., R.C.D.) and Biomedical Statistics and Informatics (Z.L.), Mayo Clinic, Rochester, MN. Dr Ashikhmina is now with the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Zhuo Li
- From the Divisions of Cardiovascular Surgery (E.A.A., H.V.S., J.A.D., T.M.S., R.M.S., S.J.P., H.M.B., R.C.D.) and Biomedical Statistics and Informatics (Z.L.), Mayo Clinic, Rochester, MN. Dr Ashikhmina is now with the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Richard C. Daly
- From the Divisions of Cardiovascular Surgery (E.A.A., H.V.S., J.A.D., T.M.S., R.M.S., S.J.P., H.M.B., R.C.D.) and Biomedical Statistics and Informatics (Z.L.), Mayo Clinic, Rochester, MN. Dr Ashikhmina is now with the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| |
Collapse
|