Risk factors for late valve-related mortality after aortic valve replacement in elderly patients

Prognosis after surgical replacement with a bioprosthetic aortic valve in patients with severe symptomatic aortic stenosis: systematic review of observational studies

OBJECTIVE

 To determine the frequency of survival, stroke, atrial fibrillation, structural valve deterioration, and length of hospital stay after surgical replacement of an aortic valve (SAVR) with a bioprosthetic valve in patients with severe symptomatic aortic stenosis.

DESIGN

 Systematic review and meta-analysis of observational studies.

DATA SOURCES

 Medline, Embase, PubMed (non-Medline records only), Cochrane Database of Systematic Reviews, and Cochrane CENTRAL from 2002 to June 2016.

STUDY SELECTION

 Eligible observational studies followed patients after SAVR with a bioprosthetic valve for at least two years.

METHODS

 Reviewers, independently and in duplicate, evaluated study eligibility, extracted data, and assessed risk of bias for patient important outcomes. We used the GRADE system to quantify absolute effects and quality of evidence. Published survival curves provided data for survival and freedom from structural valve deterioration, and random effect models provided the framework for estimates of pooled incidence rates of stroke, atrial fibrillation, and length of hospital stay.

RESULTS

 In patients undergoing SAVR with a bioprosthetic valve, median survival was 16 years in those aged 65 or less, 12 years in those aged 65 to 75, seven years in those aged 75 to 85, and six years in those aged more than 85. The incidence rate of stroke was 0.25 per 100 patient years (95% confidence interval 0.06 to 0.54) and atrial fibrillation 2.90 per 100 patient years (1.78 to 4.79). Post-SAVR, freedom from structural valve deterioration was 94.0% at 10 years, 81.7% at 15 years, and 52% at 20 years, and mean length of hospital stay was 12 days (95% confidence interval 9 to 15).

CONCLUSION

 Patients with severe symptomatic aortic stenosis undergoing SAVR with a bioprosthetic valve can expect only slightly lower survival than those without aortic stenosis, and a low incidence of stroke and, up to 10 years, of structural valve deterioration. The rate of deterioration increases rapidly after 10 years, and particularly after 15 years.

Long-Term Outcome of Prosthetic Valve Replacement in Japanese Patients Aged 65 Years or Older: Are Guidelines for Prosthetic Valve Selection Based on Overseas Data Appropriate for Japanese Patients?

BACKGROUND

Based on the revised AHA/ACC guidelines, it might be necessary to take into consideration the average life expectancy of Japanese people and revise the Japanese guidelines accordingly. Accordingly, we performed the present study to compare the long-term outcome in patients aged 65 years or older who underwent prosthetic valve replacement at our hospital using mechanical valves or biological valves.

METHODS

We have performed valve replacement in 416 patients aged 65 years or older (mechanical: 157; biological: 244).

RESULTS

There was no significant difference between the mechanical and biological valve for the actuarial survival rate. As for the valve-related complication free rate, in the mechanical valve group, the rates were significantly higher for all patients, aortic valve replacement (AVR) patients, and mitral valve replacement (MVR) patients.

CONCLUSIONS

Following revision of the AHA/ACC guidelines for selection of prosthetic valves, it is necessary to investigate whether patients aged 60-70 represent the gray zone for selecting valves as in US and European guidelines, or whether a higher age is more appropriate in view of the longer average life expectancy in Japan. Accordingly, further evaluation of the long-term outcome for mechanical and biological valves in Japanese patients is needed to obtain evidence for preparation of original Japanese guidelines on prosthetic valve selection.

Early and Long-Term Outcomes in Japanese Patients Aged 80 Years or Older Undergoing Conventional Aortic Valve Replacement

In this study, we investigated the early and long-term results of conventional aortic valve replacement (AVR) in very old patients.

METHODS

Seventy-five patients with aortic stenosis underwent conventional AVR for patients aged 80 years.We examined early death and major adverse cardiovascular and cerebrovascular event (MACCE).

RESULTS

The operative mortality was 0% for isolated AVR and 19.2% for concomitant surgery. The postoperative survival rate and MACCE free-rate were no significant differences between the isolated AVR and the concomitant surgery. Univariate analysis confirmed that cardiac dysfunction, severe chronic kidney disease (CKD), hemodialysis, + coronary artery bypass grafting, and norepinephrine use were risk factor of early death. Univariate analysis confirmed that severe CKD, BNP >1000 pg/ml, aortic cross clamping time (ACCT) >180 min, and non-use carperitide and multivariate analysis confirmed that ACCT >180 min, and non-use carperitide were risk factor of MACCE.

CONCLUSIONS

This study showed that the results of conventional AVR in very old patients were not satisfactory. However, the results obtained with isolated AVR were favorable with no operative deaths. The present study demonstrated that preoperative cardiac function, preoperative renal function, and operative factors have an important impact on early mortality and MACCE.