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Taghizadeh-Waghefi A, Petrov A, Arzt S, Alexiou K, Tugtekin SM, Matschke K, Kappert U, Wilbring M. Clinical Outcomes after Multivalve Surgery in Octogenarians: Evaluating the Need for a Paradigm Shift. J Clin Med 2024; 13:745. [PMID: 38337441 PMCID: PMC10856504 DOI: 10.3390/jcm13030745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/09/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
(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.
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Affiliation(s)
- Ali Taghizadeh-Waghefi
- Medical Faculty “Carl Gustav Carus”, Technical University of Dresden, 01307 Dresden, Germany (M.W.)
- Center of Minimally Invasive Cardiac Surgery, University Heart Center Dresden, Medical Faculty of the Technical University of Dresden, 01037 Dresden, Germany
| | - Asen Petrov
- Medical Faculty “Carl Gustav Carus”, Technical University of Dresden, 01307 Dresden, Germany (M.W.)
- Center of Minimally Invasive Cardiac Surgery, University Heart Center Dresden, Medical Faculty of the Technical University of Dresden, 01037 Dresden, Germany
| | - Sebastian Arzt
- Medical Faculty “Carl Gustav Carus”, Technical University of Dresden, 01307 Dresden, Germany (M.W.)
- Center of Minimally Invasive Cardiac Surgery, University Heart Center Dresden, Medical Faculty of the Technical University of Dresden, 01037 Dresden, Germany
| | - Konstantin Alexiou
- Medical Faculty “Carl Gustav Carus”, Technical University of Dresden, 01307 Dresden, Germany (M.W.)
- Center of Minimally Invasive Cardiac Surgery, University Heart Center Dresden, Medical Faculty of the Technical University of Dresden, 01037 Dresden, Germany
| | - Sems-Malte Tugtekin
- Medical Faculty “Carl Gustav Carus”, Technical University of Dresden, 01307 Dresden, Germany (M.W.)
- Center of Minimally Invasive Cardiac Surgery, University Heart Center Dresden, Medical Faculty of the Technical University of Dresden, 01037 Dresden, Germany
| | - Klaus Matschke
- Medical Faculty “Carl Gustav Carus”, Technical University of Dresden, 01307 Dresden, Germany (M.W.)
- Center of Minimally Invasive Cardiac Surgery, University Heart Center Dresden, Medical Faculty of the Technical University of Dresden, 01037 Dresden, Germany
| | - Utz Kappert
- Medical Faculty “Carl Gustav Carus”, Technical University of Dresden, 01307 Dresden, Germany (M.W.)
- Center of Minimally Invasive Cardiac Surgery, University Heart Center Dresden, Medical Faculty of the Technical University of Dresden, 01037 Dresden, Germany
| | - Manuel Wilbring
- Medical Faculty “Carl Gustav Carus”, Technical University of Dresden, 01307 Dresden, Germany (M.W.)
- Center of Minimally Invasive Cardiac Surgery, University Heart Center Dresden, Medical Faculty of the Technical University of Dresden, 01037 Dresden, Germany
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Zahid S, Khan MZ, Bapaye J, Altamimi TS, Elkhapery A, Thakkar S, Nepal M, Rai D, Ullah W, Patel HP, Sattar Y, Khan MU, ur Rahman A, Balla S. Outcomes, Trends, and Predictors of Gastrointestinal Bleeding in Patients Undergoing Transcatheter Aortic Valve Implantation (from the National Inpatient Sample). Am J Cardiol 2022; 170:83-90. [PMID: 35193764 DOI: 10.1016/j.amjcard.2022.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 01/02/2022] [Accepted: 01/17/2022] [Indexed: 11/26/2022]
Abstract
Major bleeding has been identified as one of the most common complications after transcatheter aortic valve implantation (TAVI) with some suffering gastrointestinal bleeding (GIB). This study aimed at assessing the incidence and predictors of GIB after TAVI in the United States. We performed a retrospective analysis of data from the National Inpatient Sample database from 2011 to 2018. A total of 216,023 hospitalizations for TAVI were included. Of the included patients, 2,188 (1%) patients had GIB, whereas 213,835 (99%) patients did not have GIB. The presence of arteriovenous malformation was associated with the highest odds of having a gastrointestinal bleed (odds ratio (OR) 24.8, 95% confidence interval (CI) 17.13 to 35.92). Peptic ulcer disease was associated with an eightfold increased risk of bleeding (OR 8.74, 95% CI, 6.69 to 11.43) followed closely by colorectal cancer (OR 7.89, 95% CI, 5.33 to 11.70). Other comorbidities that were associated with higher propensity-matched rates of GIB were chronic kidney disease (OR 1.27,95% CI, 1.14 to 1.41), congestive heart failure (OR 1.18, 95% CI,1.06 to 1.32), liver disease (OR1.83, 95% CI,1.53 to 2.19), end-stage renal disease (OR 2.08,95% CI, 1.75 to 2.47), atrial fibrillation (OR1.63,95% CI, 1.49 to 1.78), and lung cancer (OR 2.80, 95% CI,1.77 to 4.41). Patients with GIB had higher propensity-matched rates of mortality than those without GIB, (12.1% vs 3.2%, p <0.01). Patients with GIB had a higher median cost of stay ($68,779 vs $46,995, p <0.01) and a longer length of hospital stay (11 vs 3 days, p <0.01). In conclusion, health care use and mortality are higher in hospitalizations of TAVI with a GIB. Baseline comorbidities like peptic ulcer disease, chronic kidney disease, liver disease, atrial fibrillation and, colorectal cancer are significant predictors of this adverse event.
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Chen Y, Hu J, Wu S, Zhang S, Wu K, Wang W, Zhou Y. Transcatheter Mitral Valve Replacement for Treating Native Mitral Valve Disease: Current Status. Tex Heart Inst J 2021; 47:271-279. [PMID: 33472225 DOI: 10.14503/thij-18-6650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Transcatheter mitral valve replacement is increasingly being used as a treatment for high-risk patients who have native mitral valve disease; however, no comprehensive studies on its effectiveness have been reported. We therefore searched the literature for reports on patients with native mitral valve disease who underwent transcatheter access treatment. We found 40 reports, published from September 2013 through April 2017, that described the cases of 66 patients (mean age, 71 ± 12 yr; 30 women; 30 patients with mitral stenosis, 34 with mitral regurgitation, and 2 mixed) who underwent transcatheter mitral valve replacement. We documented their baseline clinical characteristics, comorbidities, diagnostic imaging results, procedural details, and postprocedural results. Access was transapical in 41 patients and transseptal in 25. The 30-day survival rate was 82.5%. The technical success rate (83.3% overall) was slightly but not significantly better in patients who had mitral regurgitation than in those who had mitral stenosis. Transapical access procedures resulted in fewer valve-in-valve implantations than did transseptal access procedures (P=0.026). These current results indicate that transcatheter mitral valve replacement is feasible in treating native mitral disease. The slightly higher technical success rate in patients who had mitral regurgitation suggests that a valve with a specific anchoring system is needed when treating mitral stenosis. Our findings indicate that transapical access is more reliable than transseptal access and that securely anchoring the valve is still challenging in transseptal access.
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Affiliation(s)
- Yan Chen
- Department of Thoracic Cardiovascular Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai 200092, People's Republic of China
| | - Junjie Hu
- Department of Thoracic Cardiovascular Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai 200092, People's Republic of China
| | - Shunqiang Wu
- Department of Thoracic Cardiovascular Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai 200092, People's Republic of China
| | - San Zhang
- Department of Thoracic Cardiovascular Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai 200092, People's Republic of China
| | - Kaiqin Wu
- Department of Thoracic Cardiovascular Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai 200092, People's Republic of China
| | - Wenli Wang
- Department of Thoracic Cardiovascular Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai 200092, People's Republic of China
| | - Yongxin Zhou
- Department of Thoracic Cardiovascular Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai 200092, People's Republic of China
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Raheja H, Ahuja KR, Nazir S, Saad AM, Gad MM, Chatterjee S, Abdelfattah OM, Hassanein M, Harb S, Kapadia SR. Association of baseline kidney disease with outcomes of transcatheter mitral valve repair by MitraClip. Catheter Cardiovasc Interv 2020; 97:E857-E867. [DOI: 10.1002/ccd.29129] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/07/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Hitesh Raheja
- Department of Cardiovascular Medicine Maimonides Medical Center Brooklyn New York
| | - Keerat Rai Ahuja
- Heart and Vascular Institute Cleveland Clinic Foundation Cleveland Ohio
| | - Salik Nazir
- Department of Cardiovascular Medicine University of Toledo Medical Center Toledo Ohio
| | - Anas M. Saad
- Heart and Vascular Institute Cleveland Clinic Foundation Cleveland Ohio
| | - Mohamed M. Gad
- Heart and Vascular Institute Cleveland Clinic Foundation Cleveland Ohio
| | - Saurav Chatterjee
- Department of Cardiovascular Medicine Long Island Jewish Medical Center Queens New York
| | | | - Mohamed Hassanein
- Heart and Vascular Institute Cleveland Clinic Foundation Cleveland Ohio
| | - Serge Harb
- Heart and Vascular Institute Cleveland Clinic Foundation Cleveland Ohio
| | - Samir R. Kapadia
- Heart and Vascular Institute Cleveland Clinic Foundation Cleveland Ohio
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Shah B, Villablanca PA, Vemulapalli S, Manandhar P, Amoroso NS, Saric M, Staniloae C, Williams MR. Outcomes After Transcatheter Mitral Valve Repair in Patients With Renal Disease. Circ Cardiovasc Interv 2020; 12:e007552. [PMID: 30704286 DOI: 10.1161/circinterventions.118.007552] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Renal disease is associated with poor prognosis despite guideline-directed cardiovascular therapy, and outcomes by sex in this population remain uncertain. METHODS AND RESULTS Patients (n=5213) who underwent a MitraClip procedure in the National Cardiovascular Data Registry Transcatheter Valve Therapy registry were evaluated for the primary composite outcome of all-cause mortality, stroke, and new requirement for dialysis by creatinine clearance (CrCl). Centers for Medicare and Medicaid Services-linked data were available in 63% of patients (n=3300). CrCl was <60 mL/min in 77% (n=4010) and <30 mL/min in 23% (n=1183) of the cohort. Rates of primary outcome were higher with lower CrCl (>60 mL/min, 1.4%; 30-<60 mL/min, 2.7%; <30 mL/min, 5.2%; dialysis, 7.8%; P<0.001), and all low CrCl groups were independently associated with the primary outcome (30-<60 mL/min: adjusted odds ratio, 2.32; 95% CI, 1.38-3.91; <30 mL/min: adjusted odds ratio, 4.44; 95% CI, 2.63-7.49; dialysis: adjusted hazards ratio, 4.52; 95% CI, 2.08-9.82) when compared with CrCl >60 mL/min. Rates of 1-year mortality were higher with lower CrCl (>60 mL/min, 13.2%; 30-<60 mL/min, 18.8%; <30 mL/min, 29.9%; dialysis, 32.3%; P<0.001), and all low CrCl groups were independently associated with 1-year mortality (30-<60 mL/min: adjusted hazards ratio, 1.50; 95% CI, 1.13-1.99; <30 mL/min: adjusted hazards ratio, 2.38; 95% CI, 1.78-3.20; adjusted hazards ratio: dialysis, 2.44; 95% CI, 1.66-3.57) when compared with CrCl >60 mL/min. CONCLUSIONS The majority of patients who undergo MitraClip have renal disease. Preprocedural renal disease is associated with poor outcomes, particularly in stage 4 or 5 renal disease where 1-year mortality is observed in nearly one-third. Studies to determine how to further optimize outcomes in this population are warranted.
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Affiliation(s)
- Binita Shah
- Department of Medicine (Cardiology), VA New York Harbor Healthcare System (Manhattan Campus) and New York University School of Medicine (B.S.)
| | - Pedro A Villablanca
- Department of Medicine (Cardiology) (P.A.V., N.S.A., M.S., C.S.), New York University School of Medicine
| | | | | | - Nicholas S Amoroso
- Department of Medicine (Cardiology) (P.A.V., N.S.A., M.S., C.S.), New York University School of Medicine
| | - Muhamed Saric
- Department of Medicine (Cardiology) (P.A.V., N.S.A., M.S., C.S.), New York University School of Medicine
| | - Cezar Staniloae
- Department of Medicine (Cardiology) (P.A.V., N.S.A., M.S., C.S.), New York University School of Medicine
| | - Mathew R Williams
- Department of Cardiothoracic Surgery (Adult Cardiac Surgery) (M.R.W.), New York University School of Medicine
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Mkalaluh S, Szczechowicz M, Dib B, Szabo G, Karck M, Weymann A. Outcomes and Predictors of Mortality After Mitral Valve Surgery in High-Risk Elderly Patients: The Heidelberg Experience. Med Sci Monit 2017; 23:6193-6200. [PMID: 29289956 PMCID: PMC5757865 DOI: 10.12659/msm.906003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Sabreen Mkalaluh
- Department of Cardiac Surgery, Heart and Marfan Center, University of Heidelberg, Heidelberg, Germany
| | - Marcin Szczechowicz
- Department of Cardiac Surgery, Heart and Marfan Center, University of Heidelberg, Heidelberg, Germany
| | - Bashar Dib
- Department of Cardiac Surgery, Heart and Marfan Center, University of Heidelberg, Heidelberg, Germany
| | - Gabor Szabo
- Department of Cardiac Surgery, Heart and Marfan Center, University of Heidelberg, Heidelberg, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, Heart and Marfan Center, University of Heidelberg, Heidelberg, Germany
| | - Alexander Weymann
- Department of Cardiac Surgery, Heart and Marfan Center, University of Heidelberg, Heidelberg, Germany.,Department of Cardiac Surgery, University Hospital Oldenburg, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
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Heart valve disease in elderly Chinese population: effect of advanced age and comorbidities on treatment decision-making and outcomes. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2016; 13:593-601. [PMID: 27605940 PMCID: PMC4996834 DOI: 10.11909/j.issn.1671-5411.2016.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Yokose S, Miura T, Hashizume K, Hisata Y, Hisatomi K, Tanigawa K, Eishi K. Long-Term Quality of Life after Cardiac and Thoracic Aortic Surgery for Very Elderly Patients 85 Years or Older. Ann Thorac Cardiovasc Surg 2016; 22:298-303. [PMID: 27507106 DOI: 10.5761/atcs.oa.15-00255] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE We evaluated the outcomes of open heart surgery and long-term quality of life for patients 85 years and older. METHODS We enrolled 46 patients 85 years and older who underwent cardiac and thoracic aortic surgery between May 1999 and November 2012. Long-term assessment was performed for 43 patients; three patients who died in the hospital were excluded. Patient conditions were assessed before surgery, 6 months and 12 months after surgery, and during the late period regarding the need for nursing care, degree of independent living, and living willingness. RESULTS Three patients (6.5%) died during hospitalization and 22 (51%) died during the follow-up period. The 1-, 3-, 5-year survival rates were 74%, 49%, and 36%. During the late period, of 21 surviving patients, 18 patients (85%) were living at home. The need for nursing care was comparable before and after surgery. The degree of independent living decreased after surgery. Living willingness was similar before and after surgery. CONCLUSION Among patients 85 years or older who underwent open heart surgery, 85% were living at home. All patients could perform activities of daily living without any assistance while maintaining living willingness.
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Affiliation(s)
- Shogo Yokose
- Division of Cardiovascular Surgery, Sasebo City General Hospital, Sasebo, Nagasaki, Japan
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Hu K, Wan Y, Hong T, Lu SY, Guo CF, Li J, Wang CS. Therapeutic Decision-Making for Elderly Patients With Symptomatic Severe Valvular Heart Diseases. Int Heart J 2016; 57:434-40. [PMID: 27396559 DOI: 10.1536/ihj.16-027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Kui Hu
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, The Shanghai Institute of Cardiovascular Diseases
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Stanger DE, Abdulla AH, Wong FT, Alipour S, Bressler BL, Wood DA, Webb JG. Upper gastrointestinal bleeding following transcatheter aortic valve replacement: A retrospective analysis. Catheter Cardiovasc Interv 2016; 90:E53-E61. [PMID: 27392808 DOI: 10.1002/ccd.26650] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 05/09/2016] [Accepted: 06/04/2016] [Indexed: 01/30/2023]
Abstract
OBJECTIVES The aim of this study was to identify the incidence of upper gastrointestinal bleeding (UGIB) in the postprocedural period following transcatheter aortic valve replacement (TAVR). BACKGROUND As TAVR moves into intermediate- and low-risk patients, it has become increasingly important to understand its extracardiac complications. The patient population undergoing TAVR have clinical and demographic characteristics that place them at significant risk of UGIB. Practical aspects of TAVR, including use of antithrombotic therapy, further increase risk of UGIB. METHODS A retrospective single-center evaluation of 841 patients who underwent TAVR between January 2005 and August 2014 was performed in conjunction with analysis of referral patterns to the gastroenterology service for UGIB at the same site. RESULTS The overall risk of UGIB following TAVR was found to be 2.0% (n = 17/841). Additionally, the risk of UGIB in patients receiving triple antithrombotic therapy was found to be 10-fold greater than patients not receiving triple antithrombotic therapy (11.8% vs 1.0%). Endoscopy findings demonstrated five high-risk esophageal lesions including erosive esophageal ulcers, visible vessels at the GE junction, erosions at distal esophagus, and an actively bleeding esophageal ring that had been intubated through by the transesophageal echocardiography (TEE) probe. CONCLUSIONS This large cohort study demonstrates that TAVR is associated with a moderate risk of severe UGIB. The results of this study suggest that patients on triple antithrombotic therapy are at highest risk for severe UGIB. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Dylan E Stanger
- Division of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alym H Abdulla
- Division of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Frank T Wong
- Division of Gastroenterology, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sina Alipour
- Division of Cardiology, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Brian L Bressler
- Division of Gastroenterology, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - David A Wood
- Division of Cardiology, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - John G Webb
- Division of Cardiology, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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Andalib A, Mamane S, Schiller I, Zakem A, Mylotte D, Martucci G, Lauzier P, Alharbi W, Cecere R, Dorfmeister M, Lange R, Brophy J, Piazza N. A systematic review and meta-analysis of surgical outcomes following mitral valve surgery in octogenarians: implications for transcatheter mitral valve interventions. EUROINTERVENTION 2014; 9:1225-34. [PMID: 24035898 DOI: 10.4244/eijv9i10a205] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
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.
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Affiliation(s)
- Ali Andalib
- Department of Medicine, Division of Cardiology, Interventional Cardiology, McGill University Health Centre, Montreal, Quebec, Canada
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Biancari F, Schifano P, Pighi M, Vasques F, Juvonen T, Vinco G. Pooled estimates of immediate and late outcome of mitral valve surgery in octogenarians: a meta-analysis and meta-regression. J Cardiothorac Vasc Anesth 2013; 27:213-9. [PMID: 23507013 DOI: 10.1053/j.jvca.2012.11.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
- Fausto Biancari
- Department of Surgery, Oulu University Hospital, Oulu, Finland.
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Seeburger J, Falk V, Garbade J, Noack T, Kiefer P, Vollroth M, Mohr FW, Misfeld M. Mitral valve surgical procedures in the elderly. Ann Thorac Surg 2012; 94:1999-2003. [PMID: 22835550 DOI: 10.1016/j.athoracsur.2012.05.069] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2011] [Revised: 05/08/2012] [Accepted: 05/11/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Mitral valve (MV) surgical procedures in the elderly are associated with profound operative and long-term mortality. We report our experience and results for MV surgical procedures in the elderly, especially with regard to the influence of comorbidities. METHODS Our hospital database was assessed to identify all patients who underwent MV surgical procedures at the age of 70 years and older between 1999 and 2009. The data were retrospectively analyzed. RESULTS A total of 2,503 patients operated on during this 10-year period were identified. In 97% of patients, mitral regurgitation (MR) was the primary indication for operation, followed by coronary artery disease in 41.6% and aortic valve stenosis in 21.3%. The 30-day mortality rate was 3.1%, and the long-term survival at 5 years was 55.2% (95% confidence interval, 52.3% to 57.5%). Coronary artery bypass grafting was identified to be associated with inferior short-term and long-term survival. Numerous comorbidities significantly influenced long-term survival. The observed mortality was significantly lower than predicted by EuroSCORE (17.2%). CONCLUSIONS MV operations in the elderly can be performed with a low early mortality and promising long-term survival. However, our large series demonstrates that comorbidities are to be attributed as the real burden for successful treatment of elderly patients undergoing MV procedures.
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Affiliation(s)
- Joerg Seeburger
- Department of Cardiac Surgery, University Heart Center Leipzig, Germany.
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15
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Vasques F, Messori A, Lucenteforte E, Biancari F. 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. Am Heart J 2012; 163:477-85. [PMID: 22424020 DOI: 10.1016/j.ahj.2011.12.005] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 12/18/2011] [Indexed: 01/02/2023]
Abstract
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.
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McClure RS, Cohn LH. Minimally invasive surgery for aortic stenosis in the geriatric patient: where are we now? ACTA ACUST UNITED AC 2012. [DOI: 10.2217/ahe.11.84] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Minimally invasive aortic valve surgery has evolved with time and become the routine approach for aortic surgery in select surgical centers. The success of these procedures in the nonelderly has led some to embark on using minimal access techniques in the geriatric population as well. With the geriatric community often inflicted with the greatest disease burden, suffering not only from a valvular process but also cumulative comorbidities, geriatric patients may be the patients most likely to derive benefit from a minimally invasive approach. Alternative therapies for symptomatic aortic stenosis include conventional full-sternotomy aortic valve replacement in addition to transcatheter aortic valve implantation. Each option has its advantages and disadvantages. The role of minimal access aortic valve surgery and its impact on the progressively aging population in the face of conventional surgery and transcatheter technology is discussed.
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Affiliation(s)
- R Scott McClure
- Harvard Medical School, Division of Cardiac Surgery, Brigham & Women’s Hospital, Boston, MA 02115, USA
| | - Lawrence H Cohn
- Harvard Medical School, Division of Cardiac Surgery, Brigham & Women’s Hospital, Boston, MA 02115, USA
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Citro R, Rigo F, Previtali M, Ciampi Q, Canterin FA, Provenza G, Giudice R, Patella MM, Vriz O, Mehta R, Baldi C, Mehta RH, Bossone E. Differences in Clinical Features and In-Hospital Outcomes of Older Adults with Tako-Tsubo Cardiomyopathy. J Am Geriatr Soc 2011; 60:93-8. [DOI: 10.1111/j.1532-5415.2011.03730.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Rodolfo Citro
- Department of Cardiology; University Hospital “San Giovanni di Dio e Ruggi d'Aragona”; Salerno
| | - Fausto Rigo
- Department of Cardiology; dell'Angelo Hospital; Mestre
| | - Mario Previtali
- Department of Cardiology; Istituto Di Ricovero e Cura a Carattere Scientifico; Fondazione Policlinico San Matteo; University of Pavia School of Medicine; Pavia
| | - Quirino Ciampi
- Department of Cardiology; Ospedale Fatebenefratelli; Benevento
| | | | | | - Roberta Giudice
- Department of Cardiology; University Hospital “San Giovanni di Dio e Ruggi d'Aragona”; Salerno
| | | | - Olga Vriz
- Department of Cardiology; Ospedale di Rete per Acuti; Udine; Italy
| | - Rahul Mehta
- Michigan State University; Lansing; Michigan
| | - Cesare Baldi
- Department of Cardiology; University Hospital “San Giovanni di Dio e Ruggi d'Aragona”; Salerno
| | | | - Eduardo Bossone
- Department of Cardiac Surgery; Istituto Di Ricovero e Cura a Carattere Scientifico; Policlinico San Donato Milanese; Milan; Italy
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Outcome after valve surgery in octogenarians and efficacy of early mobilization with early cardiac rehabilitation. Gen Thorac Cardiovasc Surg 2010; 58:606-11. [DOI: 10.1007/s11748-010-0665-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2010] [Accepted: 06/14/2010] [Indexed: 10/18/2022]
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Ben-Dor I, Pichard AD, Satler LF, Okubagzi P, Torguson R, Xue Z, Kaneshige K, Goldstein SA, Syed AI, Li Y, Lemesle G, Maluenda G, Collins SD, Wang Z, Suddath WO, Kent KM, Lindsay J, Waksman R. Clinical profile, treatment assignment and clinical outcome of patients with severe aortic stenosis not eligible to participate in a clinical trial of percutaneous aortic valve replacement. Am J Cardiol 2010; 105:857-61. [PMID: 20211332 DOI: 10.1016/j.amjcard.2009.11.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Revised: 11/05/2009] [Accepted: 11/05/2009] [Indexed: 01/30/2023]
Abstract
Patients with severe aortic stenosis and considered at high surgical risk or inoperable, and not eligible for a randomized clinical trial evaluating percutaneous aortic valve replacement (PAVR), were studied. Many of the patients referred to the study did not meet the inclusion criteria and/or had conditions listed in the exclusion criteria. These patients were then deferred to other treatment modalities. The study cohort consisted of 285 patients with severe aortic stenosis referred to participate in a clinical trial of PAVR. Patients were screened for eligibility on the basis of the protocol inclusion and exclusion criteria and deferred to other treatment modalities if they did not meet the enrollment criteria. Those patients were followed clinically by telephone contact or office visits. Of the 285 patients referred for PAVR, 216 (75.8%) were not included. The leading reasons for lack of eligibility were significant peripheral vascular disease in 50 (23.1%), Society of Thoracic Surgeons score <10% in 48 (22.9%), aortic valve area >0.8 cm(2) in 30 (13.9%), significant coronary artery disease in 25 (11.6%), and renal failure in 22 (10.2%). Sixty-nine of these patients (31.9%) were treated medically, 102 (47.2%) with balloon aortic valvuloplasty, and 45 (20.9%) with surgical aortic valve replacement. Major baseline characteristics were similar. Society of Thoracic Surgeons scores were lower in the surgical group compared with the medical and balloon aortic valvuloplasty groups (10.2 +/- 2.5 vs 12.8 +/- 3.3 vs 13.7 +/- 3.3, respectively, p <0.001). During a median follow-up period of 175.5 days (range 55.7 to 344.75), the mortality rate was higher in the balloon aortic valvuloplasty group compared with the medical and surgical aortic valve replacement groups (46 [45.1%] vs 22 [31.9%] vs 10 [22.2%], respectively, p = 0.01). In conclusion, high-risk patients with severe aortic stenosis who are deferred from PAVR often do poorly and incur high mortality rates, especially when treated with balloon valvuloplasty or medical therapy, while a loss of quality of life is apparent in those treated surgically.
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Affiliation(s)
- Itsik Ben-Dor
- Division of Cardiology, Washington Hospital Center, Washington, District of Columbia
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Rodés-Cabau J, Webb JG, Cheung A, Ye J, Dumont E, Feindel CM, Osten M, Natarajan MK, Velianou JL, Martucci G, DeVarennes B, Chisholm R, Peterson MD, Lichtenstein SV, Nietlispach F, Doyle D, DeLarochellière R, Teoh K, Chu V, Dancea A, Lachapelle K, Cheema A, Latter D, Horlick E. Transcatheter aortic valve implantation for the treatment of severe symptomatic aortic stenosis in patients at very high or prohibitive surgical risk: acute and late outcomes of the multicenter Canadian experience. J Am Coll Cardiol 2010; 55:1080-90. [PMID: 20096533 DOI: 10.1016/j.jacc.2009.12.014] [Citation(s) in RCA: 760] [Impact Index Per Article: 54.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2009] [Revised: 11/11/2009] [Accepted: 12/17/2009] [Indexed: 12/29/2022]
Abstract
OBJECTIVES The aim of this study was: 1) to evaluate the acute and late outcomes of a transcatheter aortic valve implantation (TAVI) program including both the transfemoral (TF) and transapical (TA) approaches; and 2) to determine the results of TAVI in patients deemed inoperable because of either porcelain aorta or frailty. BACKGROUND Very few data exist on the results of a comprehensive TAVI program including both TA and TF approaches for the treatment of severe aortic stenosis in patients at very high or prohibitive surgical risk. METHODS Consecutive patients who underwent TAVI with the Edwards valve (Edwards Lifesciences, Inc., Irvine, California) between January 2005 and June 2009 in 6 Canadian centers were included. RESULTS A total of 345 procedures (TF: 168, TA: 177) were performed in 339 patients. The predicted surgical mortality (Society of Thoracic Surgeons risk score) was 9.8 +/- 6.4%. The procedural success rate was 93.3%, and 30-day mortality was 10.4% (TF: 9.5%, TA: 11.3%). After a median follow-up of 8 months (25th to 75th interquartile range: 3 to 14 months) the mortality rate was 22.1%. The predictors of cumulative late mortality were peri-procedural sepsis (hazard ratio [HR]: 3.49, 95% confidence interval [CI]: 1.48 to 8.28) or need for hemodynamic support (HR: 2.58, 95% CI: 1.11 to 6), pulmonary hypertension (PH) (HR: 1.88, 95% CI: 1.17 to 3), chronic kidney disease (CKD) (HR: 2.30, 95% CI: 1.38 to 3.84), and chronic obstructive pulmonary disease (COPD) (HR: 1.75, 95% CI: 1.09 to 2.83). Patients with either porcelain aorta (18%) or frailty (25%) exhibited acute outcomes similar to the rest of the study population, and porcelain aorta patients tended to have a better survival rate at 1-year follow-up. CONCLUSIONS A TAVI program including both TF and TA approaches was associated with comparable mortality as predicted by surgical risk calculators for the treatment of patients at very high or prohibitive surgical risk, including porcelain aorta and frail patients. Baseline (PH, COPD, CKD) and peri-procedural (hemodynamic support, sepsis) factors but not the approach determined worse outcomes.
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Affiliation(s)
- Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada.
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Redo Valvular Surgery in Elderly Patients. Ann Thorac Surg 2009; 87:521-5. [DOI: 10.1016/j.athoracsur.2008.09.030] [Citation(s) in RCA: 145] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2008] [Revised: 09/11/2008] [Accepted: 09/11/2008] [Indexed: 11/18/2022]
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