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Ann Thorac Surg 1998;66:699-706
© 1998 The Society of Thoracic Surgeons

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Original articles: Cardiovascular

Aortic valve replacement for octogenarians: are small valves bad?

^a Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
^b Department of Biostatistics and Epidemiology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA

Address reprint requests to Dr Lytle, Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, 9500 Euclid Ave, F25, Cleveland, OH 44195

Presented at the Thirty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 26–28, 1998.

	Abstract

Top Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1. Variables studied References

 
Background. As the population ages, more octogenarians become candidates for aortic valve replacement. Many octogenarians, particularly women, have a small aortic annulus and there is uncertainty as to the optimal management of this situation in that age group.

Method. To examine this issue, we reviewed 248 octogenarians (mean age, 82.6 ± 2.3 years; 58% men) who underwent primary isolated aortic valve replacement (n = 99), or aortic valve replacement and coronary revascularization (n = 149), between 1980 and 1995. Nineteen-millimeter valves were used in 26% of the patients.

Results. In-hospital mortality was 8.9%, 5% for aortic valve replacement alone and 11.4% for aortic valve replacement and coronary revascularization. It was 12.5% for the 19-mm size valves compared with 7.7% for the bigger size valves (p = 0.24). Follow-up (mean interval, 4.4 years) demonstrated survival for all patients of 85%, 60%, and 30% and survival free from cardiovascular events of 80%, 45%, and 21% at 1, 5, and 10 postoperative years, respectively. Multivariate analysis identified triple-vessel disease and preoperative congestive heart failure as associated with increased risk for both in-hospital and late mortality (p < 0.05). Valve size did not influence late survival or event-free survival regardless of body surface area.

Conclusions. The use of small aortic valve prostheses in octogenarians does not adversely affect the incidence of early or late mortality or cardiac events.

	Introduction

Top Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1. Variables studied References

 
As the population ages, more octogenarians become candidates for aortic valve replacement (AVR) [1]. Many octogenarians, particularly women, have a small aortic annulus and there is uncertainty as to the optimal management of this situation in that age group. Small aortic prostheses may leave a residual gradient. On the other hand, aortic root enlargement may complicate an already complex procedure that usually includes bypass grafting [2–10]. Furthermore, many octogenarians with small annular size are small individuals and have a peak exercise capacity that is more limited than that of younger individuals. The purpose of this study was to examine the short- and long-term outcomes for patients 80 years of age after AVR and to see whether small valve sizes have an association with a bad late clinical outcome.

	Material and methods

Top Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1. Variables studied References

 
Between 1980 and 1995, 248 octogenarians underwent primary AVR, 99 (40%) having isolated AVR and 149 (60%) AVR with coronary artery bypass grafting (AVR+ CABG). We excluded patients undergoing cardiac reoperations or simultaneous cardiac or noncardiac procedures other than AVR or AVR+CABG.

Preoperative symptoms were classified according to New York Heart Association (NYHA) criteria. All patients underwent preoperative left heart catheterization with coronary arteriography. Categorization of the extent of coronary artery disease into single-vessel, double-vessel, triple-vessel, or left main coronary artery disease was based on a 50% or greater narrowing of a major coronary vessel or a first branch of a major vessel. Patients without coronary narrowing of 50% or greater were not considered to have coronary artery disease. Left ventricular function was evaluated by echocardiography and by the left ventriculogram, when available, and grouped by function as being normal or as having mild, moderate, or severe impairment.

Aortic valve lesions were classified as stenosis (1/4+ insufficiency), insufficiency (20 mm Hg aortic gradient), and mixed (a combination of at least 1/4+ insufficiency and 20 mm Hg aortic gradient). Fourteen patients (5.6%) had isolated aortic insufficiency.

Prosthesis selection was according to surgeon preference. Most patients (92%) received bioprostheses (Carpentier-Edwards bovine pericardium valve, 121 patients; Carpentier-Edwards porcine valve, 95 patients; Hancock porcine valve, 3 patients; Ionescu-Shiley bovine pericardium valve, 8 patients). In 21 patients we used St. Jude mechanical valve. In 64 (26%) patients we used 19-mm valves; larger valve sizes were used in the rest of the patients. In the mechanical valves subgroup, 12 (57%) patients received a 19-mm valve and 9 (43%) patients received a 21-mm valve.

Criteria for classifying the postoperative events and death were according to reporting guidelines of The Society of Thoracic Surgeons [11], except for late episodes of bleeding which we defined, rather than anticoagulant-related bleeding, as late bleeding occurring either in the presence or absence of anticoagulation. In addition, postoperative myocardial infarction was defined as new q waves in an electrocardiogram or elevation of myocardial enzymes. Postoperative bleeding refers to patients who needed reexploration of the chest because of excessive bleeding. Renal failure was defined as renal failure requiring at least temporary dialysis. Respiratory failure was defined as mechanical ventilation of more than 48 hours or readmission to the intensive care unit because of respiratory problems, reintubation, or respiratory arrest. Sternal wound infection was defined as deep wound infection involving the sternum. Postoperative gastrointestinal complication was defined as gastrointestinal complication that necessitated intervention, either surgical or by endoscopy. The period of time between the patient’s arrival to the intensive care unit (ICU) and the time the patient left the ICU is the ICU stay. The period of time from the operation until discharge from the hospital is the hospital stay.

Follow-up data were obtained by mail questionnaires and telephone contact by trained personnel. Patients were contacted at a mean follow-up interval of 4.4 years; follow-up was 100% complete.

A list of the variables analyzed for early and late events is presented in Appendix 1. Data were assessed by univariate analysis (t test, ², or Fisher’s exact test when appropriate). All variables that achieved p less than 0.2 in the univariate analysis were included in a multivariate model and examined by actuarial analysis, logistic regression for early events, and Cox multivariate analysis method for late events. Deaths from all causes were considered in the actuarial analyses except when indicated. Annualized rates for events are calculated and presented for descriptive purposes. Because rates can include multiple events for a patient, no statistical comparison between annualized rates was done. Statistical significance was defined as p less than 0.05.

	Results

Top Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1. Variables studied References

 
Patient population
For examination of valve size, the patients were divided into two groups. One group included patients with small valve size (SVS), defined here as patients who received a 19-mm valve. The second group included patients with bigger than 19-mm valve sizes (BVS). Patients with SVS were associated with female sex, older age, smaller body surface area (BSA), smaller aortic valve area, higher preoperative gradient across the valve, less smoking history, less circumflex coronary artery disease, and more degenerative calcified aortic stenosis, as presented in Table 1.

Morbidity
Thirty-five percent of patients experienced at least one complication after the operation. The most common complications were respiratory failure (21%) and reexploration for bleeding (10.5%). The rate of postoperative new-onset atrial fibrillation was 58%. The SVS patients had more complications (42.2%) compared with the BVS patients (31.7%), but this did not achieve statistical significance (p = 0.13) (Table 4). We performed multivariate logistic regression analysis of the preoperative variables for each postoperative complication. The isolated risk factors for each postoperative complication, as identified by multivariate analysis, are presented in Table 5. Preoperative CHF and smaller BSA were found to be associated with a higher likelihood of developing any postoperative complication, excluding atrial fibrillation.

View larger version (15K): [in this window] [in a new window]   Fig 1. Overall survival and event-free survival for all study groups.

View larger version (21K): [in this window] [in a new window]   Fig 2. Overall survival and event-free survival according to type of operation. (AVR = aortic valve replacement; AVR+CABG = AVR and coronary artery bypass grafting; NS = not significant.)

View larger version (19K): [in this window] [in a new window]   Fig 3. Overall survival and event-free survival according to valve size. (NS = not significant.)

View larger version (19K): [in this window] [in a new window]   Fig 4. Overall survival and event-free survival according to valve size for patients with body surface area (BSA) greater than 1.7 m2. (NS = not significant.)

View larger version (19K): [in this window] [in a new window]   Fig 5. Overall survival according to risk factors. (CHF = presence of CHF but not TVD; TVD = presence of TVD but not CHF; -TVD-CHF = no triple-vessel disease [TVD] and no congestive heart failure [CHF]; +TVD+CHF = presence of both TVD and CHF.)

	Comment

Top Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1. Variables studied References

 
Even for relatively elderly patients, aortic valve disease can have a major negative effect on life expectancy if left untreated. A study of 50 patients with a mean age of 77 years found that only 25% survived 3 years after they were found to have significant aortic stenosis [13]. Balloon dilation of the aortic valve, initially considered to be an attractive alternative treatment for elderly patients with aortic stenosis, proved to produce poor medium- and long-term results [14, 15]. Despite some increase in the surgical risk for these elderly patients, our results here support previous data from other groups demonstrating that octogenarians may benefit from AVR [16–22].

The octogenarian patients in this series who underwent AVR had an overall in-hospital mortality of 8.9% and a 1-, 5-, and 10-year total survival of 85%, 60%, and 30%, respectively. The survival of these patients was not different from the expected survival for octogenarians in the general population matched by age and sex. Furthermore, the quality of life of the long-term survivors measured by event-free survival and functional class was also extremely good.

For patients with coronary artery disease who also underwent bypass grafting in addition to AVR there was a trend toward an increased in-hospital mortality rate (11.4%). But this was not a statistically significant increase, and overall, the presence of coronary artery disease did not affect long-term outcome. The subset of patients with coronary artery disease who had TVD did have increased early and late mortality rates, and the presence of CHF also increased the risk of death. However, it is striking that for patients who did not have either TVD or CHF at the time of their operation, their 5-year survival rate was 81%, a remarkable figure for patients who by the end of 5 postoperative years were at least 85 years old.

In-hospital complications were relatively common for these elderly patients. Especially of note was the high rate of postoperative atrial fibrillation (58%). However, atrial fibrillation did not appear to be associated with increased hospital stay or increased risk. Respiratory failure, either primary or secondary to the occurrence of pneumonia, was also relatively common (21%), and multivariate analysis did identify the presence of respiratory failure after operation as a factor associated with increased in-hospital mortality rate. Sepsis, although not as common, was also found to be a risk factor for in-hospital death. The lengths of stay both in the ICU and in-hospital to discharge were long but were heavily affected by the very long stays of a few complicated patients, accounting for the large difference between the mean ICU stay (6.1 days) and the median stay (2.2 days). Preoperative renal dysfunction (creatinine > 1.6 mg/dL), unstable angina, and chronic obstructive lung disease were risk factors for longer in-hospital stay.

Small aortic annulus
Because it is currently unclear whether elderly patients with a small aortic annulus should undergo AVR with a 19-mm valve [2, 5, 6, 9, 23] or a more complicated procedure including aortic root enlargement to allow the insertion of a bigger valve [3, 4, 8, 10], a focus of this study was to see whether placement of a 19-mm prosthesis compromised outcomes.

Twenty-six percent of the patients in this study (SVS group) received a 19-mm valve. There was a clear association of 19-mm valve size with female sex and a small BSA. The SVS patients did exhibit trends toward a higher in-hospital mortality rate and a higher incidence of in-hospital complications when compared with patients who received larger valves, but those differences were not significant with either univariate or multivariate testing. Also, there was no difference in the length of hospital stay based on valve size. Most importantly, with up to 9 years of follow-up, survival, event-free survival, and NYHA functional class were not related to valve size.

We also specifically examined valve size in relationship to BSA. It has been suggested by Kratz and associates [3] that patients with BSA greater than 1.9 m² or even patients with BSA greater than 1.7 m² who receive small size St. Jude valves are more likely to experience late sudden death. He and coworkers [6] have suggested that BSA greater than 1.7 m² is a predictor of late death for patients who require concomitant CABG in addition to receiving small valves. On the other hand, Sawant and colleagues [24] did not find BSA greater than 1.7 m² to be a risk factor for long-term survival in patients who received 19-mm St. Jude valves. In our study 19 patients received 19-mm valves and had a BSA greater than 1.7 m² (1.8 ± 0.08; range, 1.72 to 1.98 m²). There was no in-hospital mortality among these patients, and the long-term survival and event-free survival were similar to those who had larger valves and a BSA greater than 1.7 mm² (p = 0.98 and p = 0.86, respectively).

Our previous studies concerning AVR and AVR + CABG for patients in all age groups have convinced us that older patients have a lower late death rate if they receive tissue valves [25, 26]. In this study, the type of valve that was used (mechanical versus tissue) did not appear to affect survival, but very few patients received mechanical prostheses, making conclusions on this issue invalid. To avoid the risks of anticoagulation we prefer to use tissue valves for octogenarians, and based on the findings of this study we are comfortable using 19-mm pericardial valves as aortic valve prostheses except for patients with an extremely large BSA.

Conclusions
We conclude that AVR can favorably be performed in octogenarians. The addition of CABG operation is associated with a trend toward an increased in-hospital mortality but does not seem to affect the long-term outcome. Patients without preoperative CHF and TVD who undergo isolated AVR are the most favorable subgroup of patients for both short- and long-term outcome. Octogenarians with a small aortic annulus can safely undergo AVR with a 19-mm tissue valve.

	Acknowledgments

Top Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1. Variables studied References

 
We gratefully thank Maura Schnauffer for her assistance with the preparation of the manuscript.

	Appendix 1. Variables studied

Top Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1. Variables studied References

 
Preoperative variables studied

Age

Sex

Body surface area

Blood urea nitrogen

Blood creatinine

Hypertension

Diabetes

Smoking history

History of myocardial infarction

Electrocardiographic signs of myocardial infarction

Peripheral vascular disease

Chronic obstructive lung disease

Unstable angina

Emergency operation

Syncope

Stroke

Congestive heart failure

Enlarged cardiothoracic ratio by chest x-ray films

New York Heart Association functional class

Aortic valve area

Aortic valve gradient

Aortic insufficiency

Extent of coronary disease (single-, double-, or triple-vessel disease)

Left main coronary artery disease

Left anterior descending coronary artery disease

Circumflex coronary artery disease

Right coronary artery disease

Left ventricular function

Intraaortic balloon pump

Emergency operation

Intraoperative variables studied

Type of operation

Valve pathology

Type of valve inserted

Prosthetic valve size

Aortic cross-clamp time

Cardiopulmonary bypass time

Type of myocardial protection

Systemic temperature on cardiopulmonary bypass

Year of operation

Postoperative variables studied

Intensive care unit length of stay

Hospital length of stay

Blood urea nitrogen

Blood creatinine

	References

Top Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1. Variables studied References

 

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