Aortic Valve Replacement With or Without Coronary Artery Bypass Graft Surgery: The Risk of Surgery in Patients ≥80 Years Old

The impact of coronary artery bypass grafting added to aortic valve replacement on long-term outcomes in octogenarian patients: a reconstructed time-to-event meta-analysis

The long-term results in studies comparing octogenarian patients who received either isolated surgical aortic valve replacement (i-SAVR) or coronary artery bypass grafting (CABG) in addition to SAVR are still debated. We performed a reconstructed time-to-event data meta-analysis of studies comparing i-SAVR and CABG+SAVR to evaluate the impact of CABG and to analyse the time-varying effects on long-term outcome. We performed a systematic review of the literature from January 2000 through November 2021, including studies comparing i-SAVR and CABG+SAVR, which reported at least 3-year follow-up and that plotted Kaplan–Meier curves of overall survival. The primary endpoint was overall long-term survival; secondary endpoints were in-hospital/30-day mortality and postoperative outcomes. The pooled hazard ratio (HR) and odds ratio) with 95% confidence interval (CI) were calculated for primary and secondary endpoints, respectively. Random-effect model was used in all analyses. Sixteen retrospective studies were included (5382 patients, i-SAVR = 2568 and CABG+SAVR = 2814). I-SAVR showed a lower incidence of in-hospital mortality compared to CABG+SAVR (odds ratio = 0.73; 95% CI= 0.60–0.89; P = 0.002). Landmark analyses showed a significantly higher all-cause mortality within 1 year from surgery in CABG+SAVR (HR = 1.17; 95% CI = 1.01–1.36; P = 0.03); after 1 year, no significant difference was observed (HR = 0.95; 95% CI = 0.87–1.04; P = 0.35). Landmark analysis was confirmed by time-varying trend of HR. Late survival of octogenarians did not differ significantly between the 2 interventions. Interestingly, CABG added to SAVR was associated with both higher in-hospital and within 1-year mortality after surgery, whereas this difference was statistically non-significant at long-term follow-up.

The early and long-term outcomes of coronary artery bypass grafting added to aortic valve replacement compared to isolated aortic valve replacement in elderly patients: a systematic review and meta-analysis

In aged population, the early and long-term outcomes of coronary revascularization (CABG) added to surgical aortic valve replacement (SAVR) compared to isolated SAVR (i-SAVR) are conflicting. To address this limitation, a meta-analysis comparing the early and late outcomes of SAVR plus CABG with i-SAVR was performed. Electronic databases from January 2000 to November 2021 were screened. Studies reporting early-term and long-term comparison between the two treatments in patients over 75 years were analyzed. The primary endpoints were in-hospital/30-day mortality and overall long-term survival. The pooled odd ratio (OR) and hazard ratio (HR) with 95% confidence interval (CI) were calculated for in-early outcome and long-term survival, respectively. Random-effect model was used in all analyses. Forty-four retrospective observational studies reporting on 74,560 patients (i-SAVR = 36,062; SAVR + CABG = 38,498) were included for comparison. The pooled analysis revealed that i-SAVR was significantly associated with lower rate of early mortality compared to SAVR plus CABG (OR = 0.70, 95% CI 0.66–0.75; p < 0.0001) and with lower incidence of postoperative acute renal failure (OR = 0.65; 95% CI 0.50–0.91; p = 0.02), need for dialysis (OR = 0.65; 95% CI 0.50–0.86; p = 0.002) and prolonged mechanical ventilation (OR = 0.57; 95% CI 0.42–0.77; p < 0.0001). Twenty-two studies reported data of long-term follow-up. No differences were reported between the two groups in long-term survival (HR = 0.95; 95% CI  0.87–1.03; p = 0.23). CABG added to SAVR is associated with worse early outcomes in terms of early mortality, postoperative acute renal failure, and prolonged mechanical ventilation. Long-term survival was comparable between the two treatments.

Cardiac surgical outcome prediction by blood pressure variability indices Poincaré plot and coefficient of variation: a retrospective study

Background

Recent literature suggests a significant association between blood pressure variability (BPV) and postoperative outcomes after cardiac surgery. However, its outcome prediction ability remains unclear. Current prediction models use static preoperative patient factors. We explored the ability of Poincaré plots and coefficient of variation (CV) by measuring intraoperative BPV in predicting adverse outcomes.

Methods

In this retrospective, observational, cohort study, 3687 adult patients (> 18 years) undergoing cardiac surgery requiring cardio-pulmonary bypass from 2008 to 2014 were included. Blood pressure variability was computed by Poincare plots and CV. Standard descriptors (SD) SD1, SD2 were measured with Poincare plots by ellipse fitting technique. The outcomes analyzed were the 30-day mortality and postoperative renal failure. Logistic regression models adjusted for preoperative and surgical factors were constructed to evaluate the association between BPV parameters and outcomes. C-statistics were used to analyse the predictive ability.

Results

Analysis found that, 99 (2.7%) patients died within 30 days and 105 (2.8%) patients suffered from in-hospital renal failure. Logistic regression models including BPV parameters (standard descriptors from Poincare plots and CV) performed poorly in predicting postoperative 30-day mortality and renal failure [Concordance(C)-Statistic around 0.5]. They did not add any significant value to the standard STS risk score [C-statistic: STS alone 0.7, STS + BPV parmeters 0.7].

Conclusions

In conclusion, BP variability computed from Poincare plots and CV were not predictive of mortality and renal failure in cardiac surgical patients. Patient comorbid conditions and other preoperative factors are still the gold standard for outcome prediction. Future directions include analysis of dynamic parameters such as complexity of physiological signals in identifying high risk patients and tailoring management accordingly.

Transcatheter or surgical treatment of severe aortic stenosis and coronary artery disease: A comparative analysis from the Italian OBSERVANT study

BACKGROUND

To assess clinical outcomes of patients with concomitant severe aortic stenosis (AS) and coronary artery disease (CAD) who underwent transcatheter aortic valve implantation (TAVI) and percutaneous coronary intervention (PCI) or surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG).

METHODS

Data were extracted from the multicenter OBSERVANT study. For the purposes of the present analysis, we included only patients with established stable CAD meeting any of the following inclusion criteria: 1) TAVI patients with CAD undergoing staged PCI or TAVI and PCI in the same session; 2) SAVR patients undergoing combined SAVR and CABG in the same session.

RESULTS

After propensity-score matching, a total of 472 patients (236 per group) were identified. Among TAVI patients, PCI was performed prior to the procedure in 217 patients (92.0%), whereas concomitant TAVI and PCI were performed in 19 patients (8.0%). At 3-year, there was no difference in survival between the two groups (KM estimate of freedom from death for SAVR and TAVI patients of 0.742 and 0.650, respectively; log-rank p-value of 0.105). The rate of MACCE was comparable between the two groups (KM estimate of freedom from MACCE for SAVR and TAVI patients of 0.683 and 0.582, respectively; log-rank p-value of 0.115).

CONCLUSIONS

In patients with associated severe AS and CAD, percutaneous treatment (TAVR and staged or concomitant PCI) was comparable to surgical treatment (SAVR and concomitant CABG) with respect to the early and mid-term risk of death from any cause, myocardial infarction, stroke and unplanned revascularization.

Complexity of preoperative blood pressure dynamics: possible utility in cardiac surgical risk assessment

Complexity measures are intended to assess the cardiovascular system's capacity to respond to stressors. We sought to determine if decreased BP complexity is associated with increased estimated risk as obtained from two standard instruments: the Society of Thoracic Surgeons' (STS) Risk of Mortality and Morbidity Index and the European System for Cardiac Operative Risk Evaluation Score (EuroSCORE II). In this observational cohort study, preoperative systolic, diastolic, mean (MAP) and pulse pressure (PP) time series were derived in 147 patients undergoing cardiac surgery. The complexity of the fluctuations of these four variables was quantified using multiscale entropy (MSE) analysis. In addition, the traditional time series measures, mean and standard deviation (SD) were also computed. The relationships between time series measures and the risk indices (after logarithmic transformation) were then assessed using nonparametric (Spearman correlation, r_s) and linear regression methods. A one standard deviation change in the complexity of systolic, diastolic and MAP time series was negatively associated (p < 0.05) with the STS and EuroSCORE indices in both unadjusted (21-34%) and models adjusted for age, gender and SD of the BP time series (15-31%). The mean and SD of BP time series were not significantly associated with the risk index except for a positive association with the SD of the diastolic BP. Lower preoperative BP complexity was associated with a higher estimated risk of adverse cardiovascular outcomes and may provide a novel approach to assessing cardiovascular risk. Future studies are needed to determine whether dynamical risk indices can improve current risk prediction tools.

Prospective registry of symptomatic severe aortic stenosis in octogenarians: a need for intervention

OBJECTIVE

To study the factors associated with choice of therapy and prognosis in octogenarians with severe symptomatic aortic stenosis (AS).

STUDY DESIGN

Prospective, observational, multicenter registry. Centralized follow-up included survival status and, if possible, mode of death and Katz index.

SETTING

Transnational registry in Spain.

SUBJECTS

We included 928 patients aged ≥80 years with severe symptomatic AS.

INTERVENTIONS

Aortic-valve replacement (AVR), transcatheter aortic-valve implantation (TAVI) or conservative therapy.

MAIN OUTCOME MEASURES

All-cause death.

RESULTS

Mean age was 84.2 ± 3.5 years, and only 49.0% were independent (Katz index A). The most frequent planned management was conservative therapy in 423 (46%) patients, followed by TAVI in 261 (28%) and AVR in 244 (26%). The main reason against recommending AVR in 684 patients was high surgical risk [322 (47.1%)], other medical motives [193 (28.2%)], patient refusal [134 (19.6%)] and family refusal in the case of incompetent patients [35 (5.1%)]. The mean time from treatment decision to AVR was 4.8 ± 4.6 months and to TAVI 2.1 ± 3.2 months, P < 0.001. During follow-up (11.2-38.9 months), 357 patients (38.5%) died. Survival rates at 6, 12, 18 and 24 months were 81.8%, 72.6%, 64.1% and 57.3%, respectively. Planned intervention, adjusted for multiple propensity score, was associated with lower mortality when compared with planned conservative treatment: TAVI Hazard ratio (HR) 0.68 (95% confidence interval [CI] 0.49-0.93; P = 0.016) and AVR HR 0.56 (95% CI 0.39-0.8; P = 0.002).

CONCLUSION

Octogenarians with symptomatic severe AS are frequently managed conservatively. Planned conservative management is associated with a poor prognosis.

Complete revascularization is not a prerequisite for success in current transcatheter aortic valve implantation practice

OBJECTIVES

This study sought to assess in patients undergoing transcatheter aortic valve implantation (TAVI), the prevalence and impact of incomplete coronary revascularization defined as >50% coronary artery or graft diameter stenosis on visual assessment of the coronary angiogram.

BACKGROUND

TAVI is an established treatment option in elderly patients with aortic stenosis (AS) and a (very) high operative risk. Coronary artery disease (CAD) is often associated with AS.

METHODS

A single-center cohort of consecutive patients undergoing TAVI between November 2005 and June 2012 was evaluated for the presence of significant CAD. The decision to revascularize and pursue complete revascularization was made by heart team consensus.

RESULTS

A total of 263 consecutive patients with a mean age of 80 ± 7 years and 51% male underwent TAVI with a median follow-up duration of 16 months (interquartile range: 4.2 to 28.1 months). Significant CAD with myocardium at risk was present in 124 patients (47%), 44 of whom had had previous coronary artery bypass grafting (CABG), and the median SYNTAX score in the 81 patients without previous CABG was 9.00 (2.38 to 15.63). Staged percutaneous coronary intervention (PCI) was planned in 19 (15%) and concomitant PCI with TAVI in 20 (16%). The median post-procedural residual SYNTAX score of patients without prior CABG was 5.00 (0.13 to 9.88). Overall, 99 patients (37%) (61 with no CABG and 38 CABG patients) had incomplete revascularization after TAVI. Revascularization status did not affect clinical endpoints. Kaplan-Meier survival curves for patients with and without complete revascularization demonstrated a 1-year mortality of 79.9% versus 77.4% (p = 0.85), respectively.

CONCLUSIONS

In an elderly patient population undergoing TAVI for severe AS, a judicious revascularization strategy selection by a dedicated heart team can generate favorable mid-term outcome obviating the need for complete coronary revascularization.

Adding coronary artery bypass grafting to aortic valve replacement increases operative mortality for elderly (70 years and older) patients with aortic stenosis

OBJECTIVE

This retrospective study aimed to determine the effect of simultaneous aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) on operative outcomes and long-term survival in elderly patients with a high prevalence of comorbidity.

METHODS

One hundred and fifty-seven elderly patients (70 years old or older) undergoing isolated AVR (n = 120) or combined AVR/CABG (n = 37) were evaluated. Operative outcomes were compared between the two surgical groups. Long-term survival was also compared between the groups using the Kaplan-Meier method and long-rank (Mantel-Cox) test.

RESULTS

Operative mortality was 0.8 % for the isolated AVR group and 5.4 % for the combined AVR/CABG group (p = 0.076). The length of the intensive care unit stay for the combined AVR/CABG group was significantly longer than that for the isolated AVR group (median: 40 vs. 21 h, p = 0.008). However, the occurrence rate of hospital complications, such as reoperation for bleeding, deep sternal infection, supra-ventricular arrhythmia, and neurological complications, was similar between the two groups. Actuarial survival at 3 and 5 years was 82.3 and 80.9 % for the isolated AVR group, and 88.3 and 73.0 % for the combined AVR/CABG group, respectively (p = 0.637).

CONCLUSIONS

The satisfactory operative and long-term results in our study support a more aggressive simultaneous coronary revascularization combined with AVR for aortic valve stenosis in elderly patients.

The hidden risks of advancing age and concomitant ischemic heart disease after aortic valve replacement

BACKGROUND

Despite an increasing patient risk profile, in-hospital mortality after aortic valve replacement (AVR) has declined.

HYPOTHESIS

Advanced age, concomitant coronary artery bypass grafting (CABG), and increasing comorbidity negatively affect outcomes after AVR and do so particularly in the early months after hospital discharge, where results compare much less favorably with mortality during the first 30 days.

METHODS

The study population consisted of all patients undergoing elective AVR by a single surgeon, with and without CABG, in the decade of 2000-2009. Age, logistic EuroSCORE, diabetes, type of operation, and 30-day and 1-year mortality were recorded.

RESULTS

One hundred ninety-one patients underwent isolated AVR; 133 underwent AVR + CABG. The average age increased by 5.7 years, octogenarians by 50%, logistic EuroSCORE by 18%, and the proportion of diabetics from 4% to 25.5%. Concomitant CABG surgery increased from 36% to 49%. Overall mortality for isolated AVR was zero in the first 30 days and 1.6% in the next 11 months. For AVR and CABG, mortality was 3.75% and 9%, respectively. For octogenarians, mortality was zero and 5.9% for AVR and 4.76% and 14.29% for AVR and CABG at 30 days and in the next 11 months, respectively.

CONCLUSIONS

Thirty-day mortality in all age groups remained low but was much higher in the short term after discharge from hospital, particularly in octogenarians and those with concomitant ischemic heart disease. This should inform the consent process (which traditionally concentrates on in-hospital mortality) and there should be greater awareness of the frailty and particular requirements of the elderly after discharge.

Customized Prediction of Short Length of Stay Following Elective Cardiac Surgery in Elderly Patients Using a Genetic Algorithm

Objective

To develop a customized short LOS (<6 days) prediction model for geriatric patients receiving cardiac surgery, using local data and a computational feature selection algorithm.

Design

Utilization of a machine learning algorithm in a prospectively collected STS database consisting of patients who received cardiac surgery between January 2002 and June 2011.

Setting

Urban tertiary-care center.

Participants

Geriatric patients aged 70 years or older at the time of cardiac surgery.

Interventions

None.

Measurements and Main Results

Predefined morbidity and mortality events were collected from the STS database. 23 clinically relevant predictors were investigated for short LOS prediction with a genetic algorithm (GenAlg) in 1426 patients. Due to the absence of an STS model for their particular surgery type, STS risk scores were unavailable for 771 patients. STS prediction achieved an AUC of 0.629 while the GenAlg achieved AUCs of 0.573 (in those with STS scores) and 0.691 (in those without STS scores). Among the patients with STS scores, the GenAlg features significantly associated with shorter LOS were absence of congestive heart failure (CHF) (OR = 0.59, p = 0.04), aortic valve procedure (OR = 1.54, p = 0.04), and shorter cross clamp time (OR = 0.99, p = 0.004). In those without STS prediction, short LOS was significantly correlated with younger age (OR = 0.93, p < 0.001), absence of CHF (OR = 0.53, p = 0.007), no preoperative use of beta blockers (OR = 0.66, p = 0.03), and shorter cross clamp time (OR = 0.99, p < 0.001).

Conclusion

While the GenAlg-based models did not outperform STS prediction for patients with STS risk scores, our local-data-driven approach reliably predicted short LOS for cardiac surgery types that do not allow STS risk calculation. We advocate that each institution with sufficient observational data should build their own cardiac surgery risk models.

Outcome of patients aged ≥80 years undergoing combined aortic valve replacement and coronary artery bypass grafting: a systematic review and meta-analysis of 40 studies

AIM

This study was planned to evaluate the outcome of patients aged ≥80 years undergoing combined conventional aortic valve replacement (AVR) and coronary artery bypass grafting (CABG).

METHODS

This is a systematic review of the literature and meta-analysis of data on patients aged ≥80 years who underwent combined AVR and CABG.

RESULTS

The literature search yielded 40 observational studies reporting on 8,975 patients aged ≥80 years. Pooled proportion of immediate postoperative mortality was 9.7% (95% CI 8.4-11.1, 40 studies, 8,975 patients). Immediate mortality was 8.2% (95% CI 6.5-10.0) in 15 studies with a mid-date from 2000 to 2007 and 10.8% (95% CI 9.1-12.7) in 25 studies with a mid-date from 1982 to 1999 (P = .043). Postoperative stroke rate was 3.7% (95% CI 2.8-4.8, 12 studies, 2,770 patients), and postoperative implantation of pacemaker was 4.3% (95% CI 2.6-6.5, 5 studies, 535 patients). The mean length of stay in intensive care unit was 5.3 days (95% CI 3.3-7.3, 5 studies, 490 patients), and the mean length of in-hospital stay was 16.9 days (95% CI 12.4-21.4, 5 studies, 424 patients). One-, 3-, 5- and 10-year pooled survival rates after combined AVR and CABG were 83.2%, 72.9%, 60.8%, and 25.7%, respectively.

CONCLUSIONS

Conventional AVR and CABG in patients aged ≥80 years are associated with significant operative mortality and morbidity as well as prolonged in-hospital treatment. However, conventional surgery is associated with remarkably good late survival. This suggests that any alternative treatment modality must prove itself of being enough durable also in the very elderly.

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

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.

[Update on geriatric cardiology]

This article contains a review of the main developments in the field of geriatric cardiology reported during 2010. The focus is on research into the specific characteristics of elderly patients with heart failure, ischemic heart disease, valvular heart disease and arrhythmias.