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Ann Thorac Surg 2001;71:597-600
© 2001 The Society of Thoracic Surgeons

Original article: cardiovascular

Aortic valve replacement in geriatric patients: determinants of in-hospital mortality

Larry Z. Bloomstein, BSa, Isaac Gielchinsky, MDa, Alan D. Bernstein, EngScDa, Victor Parsonnet, MDa, Craig Saunders, MDa, Ravi Karanam, MDa, Bette Graves, RNa

a Divisions of Cardiothoracic Surgery and Surgical Research, Newark Beth Israel Medical Center, Newark, New Jersey, USA

Accepted for publication August 21, 2000.

Address reprint requests to Mr Bloomstein, 9 Penwood Rd, Livingston, NJ 07039
e-mail: lbloomst{at}astro.temple.edu


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
Background. Aortic valve replacement is a common procedure in elderly patients. There has been a great deal of controversy about the risks associated with early mortality. Uncertainty of the risk associated with a small valve continues to remain controversial. This study was designed to identify the risk factors influencing early mortality and establish an accurate model for the prediction of in-hospital mortality.

Methods. One hundred eighty septuagenarians and octogenarians (58% women; mean age, 76 ± 4.7 years) underwent primary isolated aortic valve replacement between 1986 and 1997. There was an overall mortality of 16.7% (n = 180). Patients with a body surface area less than 1.8 m2 had an in-hospital mortality of 23.2% (n = 95) compared with 8.1% (n = 74; p = 0.009) for patients with a body surface area of 1.8 m2 or more. Patients with a cardiopulmonary bypass time of less than 100 minutes experienced an early mortality of 8.9% (n = 56) compared with a 10.2% (n = 59) early mortality for patients on bypass time between 100 and 124 minutes and a 29.6% (n = 64) early mortality in patients with a pump time longer than 124 minutes (p = 0.040).

Results. Multivariate logistic regression analysis identified small body surface area and long cardiopulmonary bypass time as independent risk factors. A higher mortality was seen in female patients and patients receiving smaller valves. However, there was a strong correlation between small body surface area, small valve size, and female gender.

Conclusions. Small body surface area and long cardiopulmonary bypass time are two independent risk factors in early mortality for elderly patients undergoing primary isolated aortic valve replacement. The use of small valves does not influence early mortality.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
Studies have suggested that the use of small aortic valve prosthesis in elderly patients has an adverse affect on in-hospital mortality [1–4]. Other studies have found no influence of valve size on early mortality [5–11]. Risk factors including body surface area (BSA), gender, and cardiopulmonary bypass time have also been implicated as risk factors [1, 2, 11, 12]. The purpose of this study was to determine whether small valve size is an independent risk factor in elderly patients and examine additional risk factors and their relationship to valve size. In addition, the study aimed to produce a model to predict early mortality in patients aged 70 years or older undergoing primary isolated aortic valve replacement.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
In the time period between January 1986 and December 1997, 180 patients aged 70 years or older underwent primary isolated aortic valve replacement at Newark Beth Israel Medical Center, Newark, NJ. All patients undergoing combination procedures (eg, coronary revascularization, mitral valve replacement) or reoperations were excluded from the study. The data were obtained from the hospital’s medical records. None of the operations used the minimally invasive technique and most of the operations were elective. Total body cooling to 20°C to 24°C with direct intermittent coronary infusions was used in the early 1990s as myocardial protection. A combination of retrograde and antegrade cardioplegia was used as myocardial protection in the later 1990s.

Preoperative risks studied included age, gender, New York Heart Association functional class, valve brand, valve size, BSA, bypass time, diabetes, and hypertension. Body surface area was calculated by measurement of the patient’s height and weight. Hypertension was defined as a blood pressure greater than or equal to 140/90 mm Hg or the patient was taking active medication for high blood pressure. Additional preoperative risks included smoking, chronic obstructive pulmonary disease, prolonged ischemia, atrioventricular gradient, atrioventricular area, ejection fraction, history of myocardial infarction, history of congestive heart failure, renal failure, and cerebral vascular accident. A patient was classified as a smoker with a history of smoking cigarettes at any time. Congestive heart failure was designated as a risk factor if the patient was episodic or chronic. Renal failure was defined as chronic renal failure without dialysis (creatinine, > 2 mg/dL) and cerebral vascular accident was considered as a risk factor in patients who suffered from a stroke at any point in time. Preoperative risks were collected on each patient, as summarized in Table 1. Perioperative risks included cardiopulmonary bypass time and aortic clamp durations.


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  		Table 1. Summary of the Univariate Analysis of Risks

 
Valve selection was based on surgeon’s preference. Two valves were used: the St. Jude mechanical valve (St. Jude Medical, Inc, St. Paul, MN) and the Carpentier-Edwards bioprosthesis (Baxter Health Care Corp, Santa Ana, CA). In general, the mechanical valve was used in younger patients (relative to the age group), whereas the bioprosthesis was used in older patients. Overall, 119 St. Jude valves and 61 Carpentier-Edwards valves were used. Valve size was determined by direct measurement of the aortic annulus.

Postoperative complications and causes of death of the nonsurviving patients were analyzed and categorized. Postoperative complications studied are as follows: postoperative bleeding, renal failure, respiratory failure, sepsis, wound infection, stroke, gastrointestinal problems, arrhythmia, and thromboemboli.

The data were analyzed using univariate {chi}2 analysis and multivariate logistic regression. Univariate analysis compared the individual risk factors to in-hospital mortality (death without leaving the hospital postsurgically in any time period). A p value less than or equal to 0.05 was considered statistically significant. Mean values are expressed as an average ± standard deviation.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
The results of the univariate analysis are summarized in Table 1. Univariate analysis identified four factors related to early mortality. These were small BSA, long bypass time, female gender, and small valve size.

There was an overall in-hospital mortality of 16.7% (30 of 180 patients). Patients with a small BSA (< 1.8 m2) had an in-hospital mortality of 23.2% (22 of 95 patients) compared with 8.1% (6 of 74 patients) (p = 0.0090) for patients with a larger BSA (>= 1.8 m2). Body surface area was further divided into four groups, less than 1.6, 1.6 to 1.8, more than 1.8 to 2.0, and more than 2.0 m2. The early mortality rate was 26.3% (10 of 38), 21.1% (12 of 57), 11.6% (5 of 43), and 9.7% (3 of 31 patients), respectively (p = 0.19). This approached statistical significance and there is a clear trend of increasing in-hospital mortality with decreasing BSA. This is demonstrated in Figure 1.



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  		Fig 1. Body surface area (BSA) broken down into four groups. Due to the small sample size the results are not statistically significant but a trend is evident.

 
In-hospital mortality is compared with continuous BSA in Figure 2. The trend demonstrates the relationship between BSA and early mortality. The mortality approaches zero with increasing BSA and a 0% mortality is seen in the 24 patients with a BSA more than 2.07 m2.



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  		Fig 2. Comparison of percentage in-hospital mortality with continuous body surface area (BSA). A clear trend of decreased mortality is seen with increased body surface area. (n = 169.)

 
Cardiopulmonary bypass time was divided into three groups. There was an 8.9% (n = 56) early mortality for patients on perfusion less than 100 minutes. For patients on bypass for 100 to 124 minutes the in-hospital mortality was 10.2% (n = 59) and a 29.6% (n = 54) mortality rate was seen in patients on bypass longer than 124 minutes (p = 0.040). This relationship is shown in Figure 3.



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  		Fig 3. Cardiopulmonary bypass time compared with in-hospital mortality.

 
There were 15 deaths (24.6%) in patients receiving the 19-mm valve compared with 11 deaths (20%) for 21-mm valves and 4 deaths (6.3%) for the larger size valves (p = 0.017). To examine the relationship between patients receiving small valves and patients with a small BSA the correlation was calculated. The valve size and BSA were highly correlated (p < 0.001). The average BSA of patients receiving size 19-, 21-, and 23- to 29-mm valves were 1.67 ± 0.17, 1.78 ± 0.21, 1.92 ± 0.22, respectively.

The overall mortality for women was 23.8% (n = 105) compared with 6.7% (n = 75) for the male patients (p = 0.0023). Broken down by valve size there was a 26.8% (n = 56), 24.3% (n = 37), and 8.3% (n = 12) mortality for women receiving the size 19-, 21-, and 23- to 29-mm valves, respectively. This was compared with a 0% (n = 5), 11% (n = 18), and 5.8% (n = 52) for the valve sizes 19, 21, and 23 to 39 mm, respectively.

The relationship between gender and BSA was examined. The average BSA for women was 1.7 ± 0.19, whereas the average BSA for men was 1.92 ± 0.21.

The multivariate logistic regression revealed two independent risk factors for the predication of early mortality: small BSA (p = 0.0069) and long cardiopulmonary bypass time (p = 0.0003). The variables were combined to produce an equation for prediction of early mortality: . The equation was tested using a receiver operating characteristic curve (PT = pump time). The area under the curve was 0.767 indicating accuracy of the equation. The receiver operating characteristic curve is a test of the descriptiveness of the equation. It tests the equation against the data used in the study to determine accuracy in predicting operative mortality. The curve is shown in Figure 4.



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  		Fig 4. Receiver operating characteristic curve testing the question (see text). The area under the curve is 0.767.

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
Many studies to determine the risk of valve size in aortic valve replacement have included combination procedures such as coronary artery bypass grafting [1, 3, 13–16]. Furthermore, it has been concluded that the large risk associated with coronary artery bypass grafting makes the risk associated with valve size insignificant [1, 3]. Some studies have mentioned that coronary revascularization is not a risk factor [11]. As a result of this ongoing controversy our study focused solely on patients undergoing isolated aortic valve replacement.

The results of our study indicate small BSA and long pump times are two independent risk factors associated with aortic valve replacement in patients at or older than 70 years. There is a strong correlation between female gender and small BSA. In addition, there is a strong correlation between small valve size and small BSA. For this reason the univariate analysis indicates both female gender and small valve size as risk factors. However, their correlation with small BSA explains the higher mortality rates in women and patients receiving small valves. The multivariate logistic regression identified only two independent risk factors: small BSA and extended cardiopulmonary bypass time. There is a functional relationship between early mortality and these two variables. The accuracy of the relationship was confirmed by a receiver operating characteristic curve.

This study is limited by the small sample size of patients undergoing primary isolated aortic valve replacement in patients of 70 years of age or older.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

  1. Gehlot A., Mullany C.J., Ilstrup D., et al. Aortic valve replacement in patients aged eighty years and older: early and long-term results. J Thorac Cardiovasc Surg 1996;111:1026-1036.[Abstract/Free Full Text]
  2. Kratz J.M., Sade R.M., Crawford F.A., Jr, Crumbley A.J., III, Stroud M.R. The risk of small St. Jude aortic valve prostheses. Ann Thorac Surg 1994;57:1114-1119.[Abstract]
  3. Sommers K.E., David T.E. Aortic valve replacement with patch enlargement of the aortic annulus. Ann Thorac Surg 1997;63:1608-1612.[Abstract/Free Full Text]
  4. Franzen S.F., Huljebrant I.E., Konstantinov I.E., Nylander E., Olin C.L. Aortic valve replacement for aortic stenosis in patients with small aortic roots. J Heart Valve Dis 1996;5(suppl 3):S284-S288.
  5. Gill C.C., King H.C., Lytle B.W., Cosgrove D.M., Golding L.A., Loop F.D. Early clinical evaluation after aortic valve replacement with the St. Jude Medical valve in patients with a small aortic root. Circulation 1982;66(Suppl 1):147-149.
  6. Arom K.V., Goldenberg I.F., Emery R.W. Long term clinical outcome with small size standard St. Jude Medical valves implanted in the aortic position. J Heart Valve Dis 1994;3:531-536.[Medline]
  7. He G.W., Grunkemeier G.L., Gately H.L., Furnary A.P., Starr A. Up to thirty-year survival after aortic valve replacement in the small aortic root. Ann Thorac Surg 1995;59:1056-1062.[Abstract/Free Full Text]
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