Valve surgery in the elderly

The prognostic impacts of frailty on clinical and patient-reported outcomes in patients undergoing coronary artery or valvular surgeries/procedures: A systematic review and meta-analysis

BACKGROUND

Frailty is emerging as an important prognostic indicator for patients undergoing cardiac surgeries/procedures. We sought to evaluate the prognostic and differential impacts of frailty on patients undergoing coronary artery or valvular surgical procedures of different levels of invasiveness, and to explore the differential predictability of various frailty measurement models.

METHODS

Eight databases were searched for prospective cohort studies that have adopted validated measure(s) of frailty and reported clinical, healthcare service utilization, or patient-reported outcomes in patients undergoing coronary artery or valvular surgeries/procedures.

RESULTS

Sixty-two articles were included (N = 16,679). Frailty significantly predicted mortality (short-term [≤ 30 days]: odds ratio [OR]: 2.33, 95% confidence interval [CI]: 1.28-4.26; midterm [6 months to 1 year]: OR: 3.93, 95%CI: 2.65-5.83; long-term [>1 year]: HR: 2.23, 95%CI: 1.60-3.11), postoperative complications (ORs: 2.54-3.57), discharge to care facilities (OR: 5.52, 95%CI: 3.84-7.94), hospital readmission (OR: 2.00, 95%CI: 1.15-3.50), and reduced health-related quality of life (HRQoL; standardized mean difference: -0.74, 95%CI: -1.30 to -0.18). Subgroup analyses showed that frailty exerted a greater impact on short-term mortality in patients undergoing open-heart surgeries than those receiving transcatheter procedures. Multidimensional and physical-aspect-focused frailty measurements performed equally in predicting mortality, but multidimensional measurements were more predictive of hospital readmission than physical-aspect-focused measurements.

CONCLUSION

Frailty was predictive of postoperative mortality, complications, increased healthcare service utilization, and reduced HRQoL. The impact of frailty on short-term mortality was more prominent in patients undergoing open-heart surgeries than those receiving transcatheter procedures. Multidimensional measures of frailty enhanced prognostic risk estimation, especially for hospital readmission.

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.

The impact of frailty on functional survival in patients 1 year after cardiac surgery

OBJECTIVE

This study determined whether frailty provides incremental value to the European System for Cardiac Operative Risk Evaluation II in identifying patients at risk of poor 1-year functional survival.

METHODS

This prospective study in patients undergoing cardiac surgery defined frailty using 3 common definitions: (1) the Modified Fried Criteria; (2) the Short Physical Performance Battery; and (3) the Clinical Frailty Scale. The primary outcome was functional survival, defined as being alive at 1 year postsurgery with a health-related quality of life score greater than 60 on the EuroQol-Visual Analogue Scale.

RESULTS

Of the 188 participants, 49.5%, 52.6%, and 31.9% were deemed frail according to the Modified Fried Criteria, Short Physical Performance Battery, and Clinical Frailty Scale, respectively. The median age of our cohort was 71.0 years (29.3% female). The probability of functional survival at 1 year for the entire cohort was 73.9%. After adjusting for the European System for Cardiac Operative Risk Evaluation II, patients deemed frail under the Modified Fried Criteria, Short Physical Performance Battery, and Clinical Frailty Scale had an increased odds ratio for poor functional survival of 3.44, 3.47, and 2.08, respectively. When compared with the European System for Cardiac Operative Risk Evaluation II alone, the Modified Fried Criteria, Short Physical Performance Battery, and Clinical Frailty Scale showed an absolute improvement in the discrimination slope of 6.7%, 6.5%, and 2.4% with a category-free classification improvement of 59.6%, 59.2%, and 35.1%, respectively.

CONCLUSIONS

Preoperative frailty was associated with a 2- to 3.5-fold higher risk of poor functional survival 1 year after cardiac surgery. The addition of frailty to the European System for Cardiac Operative Risk Evaluation II provides incremental value in identifying patients at risk of poor functional survival 1 year postsurgery, regardless of frailty definition.

Surgical aortic valve replacement in patients older than 75 years: is there really a quality of life benefit?

Background

To evaluate the results of elective isolated surgical aortic valve replacement (SAVR) on quality of life (QoL) in patients > 75 years.

Methods

138 patients operated between January 2008 and December 2011 were included. The EuroQOL questionnaire (EQ-5D, EQ-VAS) was completed preoperatively, and 1- and 2-years postoperatively. The logistic EuroSCORE was used for risk stratification, the Corpus Christi Heart project criteria to assess physical activity.

Results

Mean age was 79.5 ± 2.8 years, mean risk 9.7 ± 5.4, hospital mortality 2.8 %. For 115 patients (83.3 %) the preoperative QoL information was complete. Fifty patients were classified as sedentary. In the first postoperative year 13 patients died, mostly sedentary patients (p = 0.046) with a low EQ-5D (p = 0.017). There was no QoL information on 32 survivors, mostly sedentary patients (p = 0.001). The 70 patients with QoL information showed an increased QoL (NS). Two years postoperatively, 16 patients died, significantly more sedentary patients (p = 0.015) with a low EQ-5D (p = 0.006). For 42 survivors, there was no QoL information; these were mostly sedentary patients (p = 0.021). The 57 patients with 2-year QoL information had an increased EQ-5D (NS) and EQ-VAS (p = 0.024).

Conclusions

QoL increases after SAVR. However, the patients lost to follow-up were mostly sedentary or had a low preoperative QoL, which can lead to biased results.

Demographics of severe valvular aortic stenosis in Singapore

INTRODUCTION

The treatment of aortic valve stenosis (AS) is seeing renewed interest mainly due to the availability of transcatheter therapies. However, the number of epidemiological studies of this disease in Singapore is limited. We aimed to describe the aetiology and clinical presentation of AS in Singapore, as well as patients' attitudes toward it. Our findings may facilitate the future planning and utilisation of resources to better manage these patients.

METHODS

249 consecutive patients who underwent transthoracic echocardiography (from April 1999 to April 2008) and diagnosed with severe AS were assessed. Demographic and clinical data were collected, and patients' decisions on surgery were determined.

RESULTS

The mean patient age was 71 (range 23-98) years. 50.2% of patients were male. The commonest presenting symptom was dyspnoea, and 40 (16.0%) patients had coexistent atrial fibrillation. The aetiology of AS was degenerative in 216 (86.7%), rheumatic in 11 (4.4%) and related to a bicuspid valve in 22 (8.9%) patients. The average peak velocity across the aortic valve was 4.2 ± 0.8 m/s and the mean aortic valve area was 0.76 ± 0.13 cm2. The overall mean logistic EuroSCORE was 10.7 ± 12.3. 105 (42.2%) patients who were offered surgery refused. 87 (35%) deaths were seen during the follow-up period (mean duration 14.5 months), which also saw 68 (27%) patients undergo surgery and 86 (34%) patients hospitalised for heart failure.

CONCLUSION

Degenerative AS was the commonest aetiology in this contemporary cohort of patients. Despite the known benefits of surgery, the refusal rate for surgery remained high.

Quality of life after transcatheter aortic valve implantation and surgical replacement in high-risk elderly patients

AIM

The aim of this study was to compare the quality of life after transcatheter aortic valve implantation (TAVI) and surgical replacement (SAVR) at one year.

METHODS

The study included 45 consecutive high-risk patients (average age 82.0 years; logistic Euroscore 22.3%) with symptomatic severe aortic stenosis allocated to TAVI transfemoral, TAVI transapical using the Edwards-Sapien valve or SAVR with the Edwards Perimount bioprosthesis (n=15 in each). The pre-operative characteristics were similar except for more myocardial infarctions in TAVI. The quality of life was assessed using the standardized EQ-5D questionnaire at baseline and on days 30, 90 and 360. The protocol was approved by the local ethics committee and an informed consent was signed. A total of 7 patients (15.5%) died during follow-up.

RESULTS

At baseline no significant differences in any of the quality-of-life parameters were found except for usual activities described as "best" (46.7% in SAVR vs. 10.0% in TAVI; P=0.002). At 30 and 90 days surviving patients were similar and at 360 days only the anxiety/depression score was "best" in 83.3% SAVR vs. 59.1% (P=0.046). Functional status improved in all patients (NYHA class I-II in 13.3% at baseline vs. 78.9% at 360-days) and the general health median significantly improved in TAVI patients (from 50 to 67; P=0.001) with a positive trend in SAVR patients (P=0.060).

CONCLUSIONS

At one year, the general quality of life of high-risk patients had significantly improved after transcatheter aortic valve implantation with a positive trend in surgically treated patients.

Health-related quality of life after cardiac surgery

Health-related quality of life (HRQOL) assessments are designed to reflect a patient's perspective of how a disease has affected their overall health status. Patient-centered outcomes are of value both for risk assessment and as an outcome measure. Strategies for analyzing HRQOL data are inconsistent primarily because the data frequently do not meet underlying assumptions of traditional methods for statistical analyses and require a careful analytic approach.

Mitral valve replacement versus repair: propensity-adjusted survival and quality-of-life analysis

BACKGROUND

We investigated whether mitral valve repair (MVP) is superior to mitral valve replacement (MVR) in terms of survival and quality of life during the long-term follow-up.

METHODS

One hundred eighty-four consecutive patients underwent MVP or MVR for mitral regurgitation with or without concomitant coronary artery bypass grafting. Clinical data were recorded prospectively, and the data for the Nottingham Health Profile quality-of-life analysis was collected cross-sectionally. Propensity score analysis was used for the study group matching.

RESULTS

The mean follow-up time was 7.3 +/- 1.4 years. After adjustment for baseline characteristics by the propensity score method, there was a statistically significant survival benefit for the patients who underwent MVP (p = 0.02). Risk factors for death were preoperative unstable angina pectoris (relative risk ratio, 4.4; 95% confidence interval, 2.2 to 8.8), age older than 60 years (relative risk ratio, 1.1; 95% confidence interval, 1.0 to 1.1), use of mitral prosthesis (relative risk ratio, 2.7; 95% confidence interval, 1.4 to 5.3), preoperative renal insufficiency (relative risk ratio, 1.0; 95% confidence interval, 1.0 to 1.007), and preoperative cerebrovascular disorder (relative risk ratio, 2.7; 95% confidence interval, 1.0 to 5.3). The quality of life of the MVP and MVR groups did not differ from each other, but the MVP and the MVR patients had lower energy and mobility scores than an age- and sex-matched reference population.

CONCLUSIONS

Survival is longer after MVP than after MVR. The quality of life of MVP and MVR patients does not differ from each other. In terms of most quality-of-life variables, patients who undergo mitral valve operations cope similarly to an age- and sex-matched reference population. Only the scores reflecting energy and mobility were lower in the patients who were operated on than in the reference population.

Cost-effectiveness of aortic valve replacement in the elderly: an introductory study

OBJECTIVE

With increased life expectancy and improved technology, valve replacement is being offered to increasing numbers of elderly patients with satisfactory clinical results. By using standard econometric techniques, we estimated the relative cost-effectiveness of aortic valve replacement by drawing on a large prospective database at our institution. By using aortic valve replacement as an example, this introductory report paves the way to more definitive studies of these issues in the future.

METHODS

From 1961 to 2003, 4617 adult patients underwent aortic valve replacement at our service. These patients were provided with a prospective lifetime follow-up. As of 2005, these patients had accumulated 31,671 patient-years of follow-up (maximum 41 years) and had returned 22,396 yearly questionnaires. A statistical model was used to estimate the future life years of patients who are currently alive. In the absence of direct estimates of utility, quality-adjusted life years were estimated from New York Heart Association class. The cost-effectiveness ratio was calculated by the patient's age at surgery.

RESULTS

The overall cost-effectiveness ratio was approximately 13,528 dollars per quality-adjusted life year gained. The cost-effectiveness ratio increased according to age at surgery, up to 19,826 dollars per quality-adjusted life year for octogenarians and 27,182 dollars per quality-adjusted life year for nonagenarians.

CONCLUSIONS

Given the limited scope of this introductory study, aortic valve replacement is cost-effective for all age groups and is very cost-effective for all but the most elderly according to standard econometric rules of thumb.

Surgical innovations: impact on the quality of life of the older patient

As surgery has been extended into the elderly population, health-related quality of life (HRQOL) has been appropriately added as a parameter to evaluate surgical success. Surgery remains of significant risk in older patients, and an estimate of the type of outcome, including morbidity, mortality, and HRQOL can aid in that decision. New techniques, such as laparoscopic or minimally invasive surgery show great promise for reduction in perioperative stress and improved HRQOL in younger patients, but have not been extensively used in the older and frail patients for whom the benefits potentially may be greater.

State of the science for care of older adults with heart disease

This article provided an overview of the current state of knowledge related to cardiovascular disease in elders. Some depth has been provided related to CHD and HF, two common diagnoses in older persons. The most striking finding is that although trials are increasingly including older cohorts of patients, research specifically testing known therapies in older patients is essential. In particular, research testing the safety, efficacy, and acceptability of therapies in the oldest old is greatly needed.