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Saha S, Lang A, von der Linden J, Wassilowsky D, Peterss S, Pichlmaier M, Hagl C, Juchem G, Joskowiak D. Clinical Results and Quality of Life after Nonelective Cardiac Surgery in Octogenarians. Thorac Cardiovasc Surg 2022; 70:384-391. [DOI: 10.1055/s-0041-1730029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Abstract
Background We analyzed the short-term and mid-term outcomes as well as the health-related quality of life (HRQOL) of octogenarians undergoing elective and urgent cardiac surgery.
Patients and Methods We retrospectively identified 688 consecutive octogenarians who underwent cardiac surgery at our center between January 2012 and December 2019. A propensity score matching was performed which resulted in the formation of 80 matched pairs. The patients were interviewed and the Short Form-36 survey was used to assess the HRQOL of survivors. Multivariable analysis incorporated binary logistic regression using a forward stepwise (conditional) model.
Results The median age of the matched cohort was 82 years (p = 0.937), among whom, 38.8% of patients were female (p = 0.196). The median EuroSCORE II of the matched cohort was 19.4% (10.1–39.1%). The duration of postoperative mechanical ventilation was found to be independently associated with in-hospital mortality (odds ratio: 1.01 [95% confidence interval: 1.0–1.02], p = 0.038). The survival rates at 1, 2, and 5 years was 75.0, 72.0, and 46.0%, respectively. There was no difference in the total survival between the groups (p = 0.080). The physical health summary score was 41 (30–51) for the elective patients and 42 (35–49) for the nonelective octogenarians (p = 0.581). The median mental health summary scores were 56 (48–60) and 58 (52–60), respectively (p = 0.351).
Conclusion Cardiac surgery can be performed in octogenarians with good results and survivors enjoy a good quality of life; however, the indication for surgery or especially for escalation of therapy should always be made prudently, reserved, and in consideration of patient expectations.
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Affiliation(s)
- Shekhar Saha
- Department of Cardiac Surgery, Ludwig Maximilian University of Munich, Germany
| | - Andrea Lang
- Department of Cardiac Surgery, Ludwig Maximilian University of Munich, Germany
| | | | - Dietmar Wassilowsky
- Department of Anesthesiology, Ludwig Maximilian University of Munich, Germany
| | - Sven Peterss
- Department of Cardiac Surgery, Ludwig Maximilian University of Munich, Germany
| | | | - Christian Hagl
- Department of Cardiac Surgery, Ludwig Maximilian University of Munich, Germany
| | - Gerd Juchem
- Department of Cardiac Surgery, Ludwig Maximilian University of Munich, Germany
| | - Dominik Joskowiak
- Department of Cardiac Surgery, Ludwig Maximilian University of Munich, Germany
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Al-Jughiman M, Algarni K, Yau T. Outcomes of Isolated Reoperative Coronary Artery Bypass Grafting in Elderly Patients. J Card Surg 2014; 30:41-6. [DOI: 10.1111/jocs.12468] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Mohammed Al-Jughiman
- Division of Cardiac Surgery; University of Toronto; Toronto Ontario Canada
- Prince Sultan Cardiac Center; Al-Ahsa Saudi Arabia
| | - Khaled Algarni
- Division of Cardiac Surgery; University of Toronto; Toronto Ontario Canada
- King Saud University; Riyadh Saudi Arabia
| | - Terrence Yau
- Division of Cardiac Surgery; University of Toronto; Toronto Ontario Canada
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Onorati F, Biancari F, De Feo M, Mariscalco G, Messina A, Santarpino G, Santini F, Beghi C, Nappi G, Troise G, Fischlein T, Passerone G, Heikkinen J, Faggian G. Mid-term results of aortic valve surgery in redo scenarios in the current practice: results from the multicentre European RECORD (REdo Cardiac Operation Research Database) initiative†. Eur J Cardiothorac Surg 2014; 47:269-80; discussion 280. [PMID: 24686001 DOI: 10.1093/ejcts/ezu116] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Although commonly reported as single-centre experiences, redo aortic valve replacement (RAVR) has overall acceptable results. Nevertheless, trans-catheter aortic valve replacement has recently questioned the efficacy of RAVR. METHODS Early-to-mid-term results and determinants of mortality in 711 cases of RAVR from seven European institutions were assessed in the entire population and in selected high-risk subgroups [elderly >75 years, urgent/emergent procedures, preoperative New York Heart Association (NYHA) functional Class IV and endocarditis]. RESULTS Hospital mortality was 5.1%, major re-entry cardiovascular complications (MRCVCs) 4.9%, low cardiac output syndrome (LCOS) 15.3%, stroke 6.6%, acute respiratory failure (ARF) 10.6%, acute renal insufficiency (ARI) 19.3% and need for continuous renal replacement therapy (CRRT) 7.2%, transfusions 66.9% and for permanent pacemaker (PMK) 12.7%. Mid-term survival, freedom from acute heart failure (AHF), reinterventions, stroke and thrombo-embolisms were 77.2 ± 2.7, 84.4 ± 2.6, 97.2 ± 0.8, 97.2 ± 0.9 and 96.3 ± 1.2%, respectively; 87.5% of patients were in NYHA functional Class I-II. Preoperative left ventricular ejection fraction of <30% [odds ratio (OR) 8.7, 95% confidence interval (CI) 2.1-35.6], MRCVCs (OR 20.9, 95% CI 5.6-78.3), cardiopulmonary bypass time (OR 1.1, 95% CI 1.0-1.1), perioperative LCOS (OR 17.2, 95% CI 5.1-57.4) and ARI (OR 5.1, 95% CI 1.5-18.1) predicted hospital death. Endocarditis (OR 7.5, 95% CI 2.9-19.1), preoperative NYHA functional Class IV (OR 4.7, 95% CI 1.0-24.0), combined RAVR + mitral surgery (OR 5.1, 95% CI 1.5-17.3) and AHF at follow-up (OR 2.8, 95% CI 1.3-6.0) predicted late death at the Cox proportional hazard regression model. Elderly >75 years had similar hospital mortality (P = 0.06) and major morbidity, except for a higher need for PMK (P = 0.03), as well as comparable mid-term survival (P = 0.89), freedom from AHF (P = 0.81), reinterventions (P = 0.63), stroke (P = 0.21) and thrombo-embolisms (P = 0.09). Urgent/emergent indication resulted in higher hospital death, LCOS, transfusions, MRCVCs, intra-aortic balloon pumping (IABP), stroke, prolonged (>48 h) ventilation, pneumonia, ARI, CRRT, lower mid-term survival and freedom from AHF (P ≤ 0.03). Preoperative NYHA functional Class IV correlated with higher LCOS, IABP, prolonged ventilation, pneumonia, ARF, ARI, CRRT and MRCVCs and lower mid-term survival, freedom from AHF, reinterventions and stroke (P ≤ 0.02). Endocarditis demonstrated higher hospital mortality, MRCVCs, LCOS, IABP, stroke, ARF, prolonged intubation, pneumonia, ARI, CRRT, transfusions and PMK and lower mid-term survival and freedom from AHF and reinterventions (P ≤ 0.04). CONCLUSIONS RAVR achieves overall satisfactory results. Baseline risk factors and perioperative complications strongly affect outcomes and mandate improvements in perioperative management. New emerging strategies might be considered in selected high-risk cases.
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Affiliation(s)
- Francesco Onorati
- Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Fausto Biancari
- Division of Cardiac Surgery, University of Oulu, Oulu, Finland
| | - Marisa De Feo
- Department of Cardiothoracic and Respiratory Sciences, Second University of Naples, Naples, Italy
| | | | - Antonio Messina
- Cardiac Surgery Unit, Poliambulanza Foundation Hospital, Brescia, Italy
| | | | - Francesco Santini
- Division of Cardiac Surgery, IRCCS San Martino University Hospital, Genoa, Italy
| | - Cesare Beghi
- Cardiac Surgery Unit, Varese University Hospital, Varese, Italy
| | - Giannantonio Nappi
- Department of Cardiothoracic and Respiratory Sciences, Second University of Naples, Naples, Italy
| | - Giovanni Troise
- Cardiac Surgery Unit, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Theodor Fischlein
- Department of Cardiac Surgery, Klinikum Nürnberg, Nuremberg, Germany
| | - Giancarlo Passerone
- Division of Cardiac Surgery, IRCCS San Martino University Hospital, Genoa, Italy
| | - Juni Heikkinen
- Division of Cardiac Surgery, University of Oulu, Oulu, Finland
| | - Giuseppe Faggian
- Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
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Outcome of Redo Surgical Aortic Valve Replacement in Patients 80 Years and Older: Results From the Multicenter RECORD Initiative. Ann Thorac Surg 2014; 97:537-43. [DOI: 10.1016/j.athoracsur.2013.09.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Revised: 08/27/2013] [Accepted: 09/04/2013] [Indexed: 11/22/2022]
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Cardiac Reoperation in Patients Aged 80 Years and Older. Ann Thorac Surg 2009; 87:1379-85. [DOI: 10.1016/j.athoracsur.2009.01.045] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2008] [Revised: 01/17/2009] [Accepted: 01/20/2009] [Indexed: 11/20/2022]
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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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Kogan A, Ghosh P, Preisman S, Tager S, Sternik L, Lavee J, Kasiff I, Raanani E. Risk Factors for Failed “Fast-Tracking” After Cardiac Surgery in Patients Older Than 70 Years. J Cardiothorac Vasc Anesth 2008; 22:530-5. [DOI: 10.1053/j.jvca.2008.02.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2007] [Indexed: 11/11/2022]
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Kappetein AP, van Geldorp M, Takkenberg JJM, Bogers AJJC. Optimum management of elderly patients with calcified aortic stenosis. Expert Rev Cardiovasc Ther 2008; 6:491-501. [PMID: 18402539 DOI: 10.1586/14779072.6.4.491] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Increased life-expectancy has led to a growing elderly population frequently presenting with aortic stenosis. This review focuses on the pathogenesis of calcific aortic stenosis, diagnosis and possible ways to halt the progression to severe symptomatic aortic stenosis, methods of assessing symptoms and severity, and modalities and timing of aortic valve replacement. At present the treatment of aortic stenosis for the majority of patients is surgical, and any patient with symptomatic severe aortic stenosis should be considered for aortic valve replacement. This article also discusses the role of emerging techniques of closed heart valve implantation either transfemoral or transapical, and which patients might be candidates for these new approaches to the treatment of aortic stenosis in the elderly population.
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Affiliation(s)
- A Pieter Kappetein
- Department of Cardio-thoracic Surgery, Erasmus Medical Center, Room Bd 569, PO Box 2040, 3000 CA Rotterdam, The Netherlands.
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Eitz T, Schenk S, Fritzsche D, Bairaktaris A, Wagner O, Koertke H, Koerfer R. International normalized ratio self-management lowers the risk of thromboembolic events after prosthetic heart valve replacement. Ann Thorac Surg 2008; 85:949-54; discussion 955. [PMID: 18291177 DOI: 10.1016/j.athoracsur.2007.08.071] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2007] [Revised: 08/17/2007] [Accepted: 08/21/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Although prosthetic valves are durable and easy to implant, the need for lifetime warfarin-based anticoagulation restricts their exclusive usage. We investigated if anticoagulation self-management improves outcome in a single-center series. METHODS Between 1994 and 1998, 765 patients with prosthetic valve replacements were prospectively enrolled and randomized to receive conventional anticoagulation management by their primary physician (group 1, n = 295) or to pursue anticoagulation self-management (group 2, n = 470). A study head office was implemented to coordinate and monitor anticoagulation protocols, international normalized ratios (INR), and adverse events. Patients were instructed on how to obtain and test their own blood samples and to adjust warfarin dosages according to the measured INR (target range, 2.5 to 4). RESULTS Mean INR values were slightly yet significantly smaller in group 1 than in group 2 (2.8 +/- 0.7 vs 3.0 +/- .6, p < 0.001). Moreover, INR values of patients with conventional INR management were frequently measured outside the INR target range, whereas those with anticoagulation self-management mostly remained within the range (35% vs 21%, p < 0.001). In addition, the scatter of INR values was smaller if self-managed. Freedom from thromboembolism at 3, 12, and 24 months, respectively, was 99%, 95%, and 91% in group 1 compared with 99%, 98%, and 96% in group 2 (p = 0.008). Bleeding events were similar in both groups. Time-related multivariate analysis identified INR self-management and higher INR as independent predictors for better outcome. CONCLUSIONS Anticoagulation self-management can improve INR profiles up to 2 years after prosthetic valve replacement and reduce adverse events. Current indications of prosthetic rather than biologic valve implantations may be extended if the benefit of INR self-management is shown by future studies with longer follow-up.
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Affiliation(s)
- Thomas Eitz
- Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine-Westphalia, Ruhr Universität Bochum, Bad Oeynhausen, Germany.
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Hanania G, Maroni JP. [Operative risk of heart valve surgery after 80 years]. Ann Cardiol Angeiol (Paris) 2006; 54:339-43. [PMID: 17183830 DOI: 10.1016/j.ancard.2005.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The continuous prolongation of life expectancy in developed nations and the progress made in the surgical treatment of valvulopathy have substantially increased the number of octogenarians undergoing heart valve surgery with extracorporeal circulation. Most of them have calcified aortic stenosis and the valve is replaced with a bioprosthesis. At these ages, mitral valve disease--usually insufficiency--is predominantly treated by repair rather than valve replacement. In both cases, the etiology is primarily degenerative. In addition, an ever-increasing percentage of these patients require replacement of deteriorated bioprostheses. These octogenarians are exposed to surgical risk estimated to be about 9-10%, i.e. 2-3 times higher than that of patients under 70 years of age, and even higher when surgery is a reintervention. Furthermore, morbidity affecting approximately an additional third of those undergoing surgery must be added to this mortality. Therefore, only half of the patients have uncomplicated surgical outcomes. Age is not the only factor enhancing the risk, which is also linked to comorbidities, preoperative functional class, stage of the evolving valvulopathy, and association of coronary artery disease. Predictive scores (Parsonnet, EuroScore) have been devised to evaluate the surgical risk to which these patients are subjected. Rigorous selection of patients with severe valvulopathy should enable potential candidates, willing to undergo an intervention, to be provided with indications for surgery sufficiently early so as to not enhance the risk by intervening too late.
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Affiliation(s)
- G Hanania
- Service de cardiologie, hôpital Robert-Ballanger, boulevard Robert-Ballanger, 93602 Aulnay-sous-Bois, France.
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Eitz T, Fritzsche D, Kleikamp G, Zittermann A, Horstkotte D, Körfer R. Reoperation of the Aortic Valve in Octogenarians. Ann Thorac Surg 2006; 82:1385-90. [PMID: 16996938 DOI: 10.1016/j.athoracsur.2006.04.093] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2006] [Revised: 04/26/2006] [Accepted: 04/27/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Because of increasing life expectancy of patients with heart valve replacement and a limited durability of heart valve bioprostheses, cardiac reoperation becomes necessary in a significant percentage of patients. Reliable data on mortality and risk factors in octogenarians after replacement of aortic valve prostheses are scanty, however. METHODS We retrospectively analyzed 71 patients aged 80 years and older who underwent cardiac reoperation of the aortic valve (69 bioprostheses, 2 mechanical prostheses) between 1991 and 2004 at our heart center. Survival rate of the study cohort was compared with a control group of octogenarians matched for age, sex, and year of aortic valve replacement. To assess predictors of 30-day survival and 3-year survival, we performed univariate and multivariate analyses. RESULTS Survival rates at 30 days, 1 year, 3 years and 5 years were 83.6%, 76.1%, 70.8%, and 51.3%, respectively. Results did not differ significantly between the study cohort and the controls. Patients with reoperation had an estimated median survival of 5.6 years. Postoperative complications such as low cardiac output syndrome and intestinal failure were the only independent predictors of 30-day survival (p = 0.020 and p = 0.015, respectively). Low cardiac output, intestinal failure, and diabetes mellitus were independent predictors of 3-year survival (p = 0.001 to 0.033). CONCLUSIONS Our data demonstrate that it is possible to achieve an acceptable outcome in octogenarians who have reoperation of the aortic valve prosthesis. Early and mid-term survival is predominantly influenced by unexpected postoperative complications and not by preoperative risk factors, with the exception of diabetes mellitus.
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Affiliation(s)
- Thomas Eitz
- Department of Cardiothoracic Surgery, Heart and Diabetes Center NRW, North-Rhine Westfalia, Ruhr University Bochum, Bad Oeynhausen, Germany.
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Abstract
BACKGROUND The number of octogenarians receiving cardiac surgery is increasing. Concerns regarding the outcomes and significant expense required to provide this service have not been addressed because no prospective medium term outcomes of Australian octogenarians have been published. METHODS Prospective analysis was undertaken of octogenarians having cardiac surgery from 1996 to 2001 in three hospitals of moderate case volume (400 patients per year) by: in-hospital audit and data acquisition, 1-year direct patient follow up in rooms, and a final follow up in late 2001 directly with the patient either in rooms or via telephone questionnaire. RESULTS Sixty-four patients had cardiac surgery. All patients were severely disabled by symptoms (CCVS: III-IV, NYHA: III-IV) preoperatively, 14% were advised not to proceed with a surgical option but did so. Total operative in-hospital mortality was 6.3% (elective: 0%, urgent: 10.5%, P = 0.05), major complications were few 10.9% (seven patients; stroke: 1.6%, deep sternal infection: 1.6%, myocardial infarction: 1.6%, reoperation: 4.8%). At 1 year, despite 95% being free of significant cardiovascular symptoms (CCVS/NYHA: I-II), nearly one in five (19%) would not have proceeded with the surgery. However, at the final follow up (mean time: 2.8 years), freedom from cardiovascular symptoms remained high (95%), 94% remained independent and their quality of life was significantly better than before surgery. Although 59% suffered worsening of additional medical conditions, these conditions had a minor impact on their quality of life. Ninety-eight per cent would recommend cardiac surgery. Actuarial survival for all patients and for hospital survivors at 4 years was 67.9 +/- 4.1% and 74.2 +/- 4%, respectively. CONCLUSION Medium-term follow up of Australian octogenarians who were offered cardiac surgery revealed that 94% remain independent and with an excellent quality of life. Age alone must not be a barrier to access to cardiac surgery.
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Affiliation(s)
- Timothy D Hewitt
- Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
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