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Ann Thorac Surg 2000;69:317-318
© 2000 The Society of Thoracic Surgeons
a Cardiothoracic Unit, Imperial College School of Medicine, Hammersmith Hospital, Du Cane Rd, London, England W12 0NN, United Kingdom
To the Editor
We read with interest the recent publication by Craver and colleagues [1]. The authors report outcome after a variety of cardiac surgical procedures in patients aged 80 years and over, operated on between 1976 and 1994. As they point out, this is one of the largest series reported in this group of patients, although they did not include articles published after 1994 in their references. Significant strengths of their study are the comparison with younger age groups, the inclusion of relevant demographic data, and the satisfactorily high percentage of complete follow-up (89.2%). Applying selection criteria for cardiac surgery in the elderly is a difficult process that is helped considerably by publications such as the present one.
We have published the largest collective series of data, so far, on mortality and cause of death after aortic valve replacement (AVR) and mitral valve replacement (MVR) in octogenarians by analyzing information from the UK Heart Valve Registry (UKHVR) for the years 1986 to 1995 [2, 3]. In our publications, patients undergoing simultaneous coronary artery bypass grafting were incorporated in the studied population. It is our experience as well in the UK that the number of patients over the age of 80 years undergoing heart valve replacement has increased considerably in recent years. In 1986, only 0.6% of patients who underwent AVR or MVR, in the UK, were octogenarians, whereas in 1995, this percentage increased to 6.1% and is still rising. These numbers are similar to those reported by Craver and colleagues. As a result, the mean follow-up time is short (2.8 years [1] vs 3.2 years [2]). It is likely that 30-day mortality has decreased considerably over the last 10 years and, therefore, it would have been informative if Craver and colleagues had divided their results into an early and a late period. Thirty-day mortality in the UKHVR population, in patients over 80 years was 6.6% after AVR and 10.4% after MVR. The UKHVR benefits from very accurate information on 30-day and long-term mortality, obtained from the Office for National Statistics.
Furthermore, it is also likely that the numbers of octogenarian patients remaining at risk at 8 to 10 years of follow-up, in particular after MVR, are extremely small, rendering the apparent rapid decline in survival less relevant after this period (Figs 2 to 8 in reference 1).
In our study, 88% of patients undergoing AVR received a bioprosthetic valve, which is similar to the data reported by Craver and colleagues. For MVR, however, 43% of the UKHVR patients received a mechanical valve, with no difference in long 5-year survival between groups.
Based on our data, we have to disagree with the statement that "MVR has a limited role in the octogenarian population." We believe that, similarly to AVR, when adequate selection criteria are applied, this procedure can achieve satisfactory results. It is of paramount importance, however, to continue monitoring the mid- and long-term survival rates in these patients. In addition to survival, assessment of quality of life after cardiac surgery, particularly in elderly patients, should become an important end point for operative outcome. Again, we would like to congratulate the authors of this interesting study.
References
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