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Ann Thorac Surg 2004;78:807-813
© 2004 The Society of Thoracic Surgeons

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Original article: cardiovascular

Results of mitral surgery in octogenarians with isolated nonrheumatic mitral regurgitation

^a Division of Cardiovascular Surgery, Mayo College of Medicine, Rochester, Minnesota, USA

Accepted for publication March 15, 2004.

^* Address reprint requests to Dr Zehr, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
zehr.kenton{at}mayo.edu

	Abstract

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
BACKGROUND: Increasing numbers of elderly patients are now referred for mitral valve operations. It has been unclear whether the results offset the risk of intervention in this patient population.

METHODS: We obtained clinical follow-up through May 2002 of 59 patients 80 years or older who underwent first-time isolated mitral valve repair (46 patients) or replacement (13 patients) for nonischemic, nonrheumatic mitral regurgitation from January 1990 to June 2000. The mean duration of follow-up was 68 ± 33 months. Observed survival was compared with the expected survival of persons of the same age and gender in the general population.

RESULTS: Preoperatively 79% of patients were in New York Heart Association (NYHA) class III–IV. Operative mortality was 1.7%. Overall 1- and 5-year survival was 89% and 61%. One- and 5-year freedom from thromboembolic complications in hospital survivors was 97% and 84%. One- and 5-year freedom from heart-related hospitalization in hospital survivors was 89% and 78%. There were no reoperations. Twenty-nine patients underwent an echocardiographic follow-up; 31% of them exhibited moderate or more regurgitation. Of 37 surviving patients at follow-up, 78% were in NYHA functional class I–II. No statistically significant difference was noted between the observed survival postoperatively and the expected survival of persons of the same age and gender in the general population. In a univariate analysis, only preoperative left ventricular ejection fraction greater than 40% was significantly associated with freedom from late heart-related mortality (95% confidence interval 62%–92%, p = 0.01) and with freedom from heart-related hospitalization (95% CI 68%–95%, p < 0.01).

CONCLUSIONS: Native mitral valve surgery for isolated nonischemic, nonrheumatic disease in octogenarians resulted in a survival rate comparable with that of the general population. It also exhibited substantial improvement regarding the functional status of the patient. Reparative techniques did not result in a survival advantage compared with replacement but did prove to be a reliable approach. Surgery performed in an early stage, preceding the development of left ventricular dysfunction, was associated with an improved freedom from late cardiac complications.

	Introduction

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There are no definitive data from randomized trials regarding the ideal treatment for mitral regurgitation. Surgery has been associated with improved survival compared with medical treatment, independently of the base line characteristics of patients and comorbid conditions. Delahaye and associates reported an 8-year actuarial survival rate of 74% ± 4.3% after surgical treatment, but of only 33.2% ± 9.2% after medical treatment in 216 patients exhibiting severe mitral regurgitation [1]. Ling and associates reported a significantly higher mortality rate among those treated medically compared with that expected in an age- and sex-matched US population in a series of 229 patients exhibiting isolated mitral regurgitation due to flail leaflet. Those undergoing surgery experienced no excess mortality. Within 10 years of the initial diagnosis the need for surgery was almost unavoidable [2].

Mitral surgery can be performed with a low operative risk and durable results. Operative mortality for nonischemic mitral valve disease has been reported to range from 0.3%–5.4% with valve repair and 3.8%–7.2% with prosthetic replacement; 5-year freedom from reoperation ranged from 90.8%–96.9% after repair and 95.5%–96.3% after replacement. Ten-year freedom from reoperation ranged from 92.9%–94% after repair and 93.4–96% after replacement with mechanical prosthesis, whereas 10-year freedom from structural deterioration of bioprosthesis has been reported to range from 63.7%–67% [3–10]. It is unclear whether these results translate to the elderly population.

Intervention regarding the mitral valve in octogenarians raises concern. There is apprehension regarding their ability to tolerate cardiopulmonary bypass, the general quality of their tissues, uncertainty as to their life expectancy, and their quality of life with and without surgery.

We have reviewed our single institution 10-year experience regarding the repair and replacement of nonrheumatic, nonischemic mitral valve regurgitation in octogenarians in an attempt to comprehend the outcomes and the effectiveness of various surgical approaches.

	Material and methods

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Patients
From January 1990 to June 2000, 59 patients 80 years of age or older underwent first-time isolated mitral valve repair (MVRe) or replacement (MVR) at our institution. Patients having a history of rheumatic fever with operative findings consistent with rheumatic disease or with ischemic heart disease and patients undergoing concomitant aortic surgery and coronary artery bypass grafting surgery were excluded. Patients undergoing concomitant tricuspid annuloplasty, patent foramen ovale closure, or atrial septal defect closure were not excluded. Demographics as well as intraoperative and perioperative outcome data were retrospectively analyzed. The study was approved by the Mayo Clinic Internal Review Board.

Demographics
The mean age was 82 ± 2 years, 42% were female, and 79% were in preoperative New York Heart Association (NYHA) class III or IV. The etiology of mitral valve disease was degenerative in 95% and infectious in 5%. The preoperative creatinine serum level was greater than 1.4 mg/dl in 34% of the patients. Eight percent of the patients exhibited chronic obstructive pulmonary disease (COPD), 5% exhibited a history of neurologic events, and 3% were diagnosed with diabetes. Patient demographics, grouped by the type of surgery performed, are listed in Table 1.

Follow-up
Follow-up was conducted by mailed questionnaire, telephone interview, and chart review and was 98% complete. The mean follow-up was 68 ± 33 months. Late survival and valve-related outcomes were recorded as per the guidelines of the Ad Hoc Liaison Committee for Standardizing Definitions of Prosthetic Heart Valve Morbidity [11].

Statistical analysis
Postoperative survival, freedom from cardiac death, freedom from thromboembolism, freedom from bleeding, and freedom from heart-related hospitalizations were estimated using the Kaplan–Meier method. Overall survival was compared with the expected survival of persons of the same age and gender, as derived from vital statistics for the central northwest region of the United States. The statistical significance of observed versus expected survival was assessed with a one-sample log-rank test. The associations regarding potential risk factors relative to survival and complications were assessed with log-rank tests and the Cox proportional hazards model. MVR and MVRe were compared with ² tests for the categorical variables and rank-sum tests for continuous variables. Data were expressed as mean ± standard deviation and statistical significance was considered at p less than 0.05.

	Results

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Hospital outcomes
Operative mortality for all patients was 1.7% [1]; postoperative hospital stay was 11 ± 8 days (Table 1). Among potential risk factors (gender, preoperative neurologic event, preoperative COPD, preoperative creatinine serum level greater than 1.4 mg/dl, atrial fibrillation at admission, preoperative NYHA functional class III–IV, preoperative left ventricular ejection fraction [LVEF] less than 40%, preoperative pulmonary systolic pressure greater than 50 mm Hg, MVR versus MVRe, associated tricuspid valve surgery) only preoperative NYHA functional class III–IV was significantly associated with prolonged hospital stay (> 8 days) (95% confidence interval [CI] 44–75, p = 0.005). No statistical calculation of association between potential risk factors and operative mortality was possible because of the low number of operative deaths.

Late outcomes
Survival
Overall 1- and 5-year survival was 89.4% (95% CI: 81.4–97.4) and 61% (95% CI: 46.4–75.8). No statistically significant association was observed between the above-listed potential risk factors and late mortality. Comparison between overall survival of patients after mitral surgery and the expected survival of persons of the same age and gender as derived from vital statistics for the central northwest region of the United States did not result in any statistically significant difference (p = 0.75) (Fig 1).

View larger version (11K): [in this window] [in a new window]   Fig 1. Survival observed after mitral valve surgery and expected survival in the general population of the same age (n = patients at risk).

View larger version (8K): [in this window] [in a new window]   Fig 2. Freedom from cardiac death (n = patients at risk).

Thromboembolic events
One- and 5-year freedom from thromboembolic complications in hospital survivors was 96.6% (95% CI: 91.6–100) and 84.1% (95% CI: 70.9–96) (Fig 3). No statistically significant association was observed between potential risk factors (gender, preoperative neurologic event, atrial fibrillation at admission, preoperative LVEF less than 40%, MVR versus MVRe, associated tricuspid valve surgery, lack of oral anticoagulation at follow-up, lack of antiplatelet therapy at follow-up) and thromboembolic complications.

View larger version (8K): [in this window] [in a new window]   Fig 3. Freedom from thromboembolic events (n = patients at risk).

View larger version (8K): [in this window] [in a new window]   Fig 4. Freedom from bleeding events (n = patients at risk).

Heart-related hospitalization
One- and 5-year freedom from heart-related hospitalization in hospital survivors was 89.3% (95% CI: 81.3–97.8) and 78.3% (95% CI: 64.7–92.1). Preoperative LVEF greater than 40% was significantly associated with freedom from heart-related hospitalization (95% CI 68%–95%) (p < 0.01).

Echocardiographic follow-up
Upon prescription of the attending physicians, transthoracic Doppler echocardiographic follow-up studies were available for 29 patients (7 MVR patients, 22 MVRe patients; mean time from surgery 31–25 months). Eleven patients (38%) exhibited no mitral regurgitation, 9 patients (31%) exhibited mild regurgitation, and 9 patients (31%) exhibited moderate or greater regurgitation.

Nyha functional class
Of 37 surviving patients, 29 (78%) were designated as NYHA functional class I–II at follow-up.

	Comment

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Increasing numbers of elderly patients are now referred for cardiac operations. Large multihospital practices have witnessed an upward trend in the mean age of adult patients undergoing heart surgery [12]. Akins and associates reported that the number of octogenarians undergoing cardiac operations rose from less than 15 cases in 1985 to more than 105 in 1995 [13]. Several reports regarding the outcomes after heart-valve surgery in nonagenarians have been published [14, 15].

The efficacy of mitral valve surgery with regard to elderly patients is still controversial. Mitral surgery in patients 80 years of age or older has been associated with a high operative mortality (175–29%) [16, 17]. Patients with ages greater than or equal to 65 years or greater than or equal to 75 years have been associated with high operative risk[12, 18–20]. The presence of considerable comorbidities may potentially provide an explanation regarding these reported poor outcomes.

In contrast several studies regarding mitral surgery in the elderly report favorable outcomes. Operative mortality has been reported as low as 3.7% [21] and excellent long-term survival has been reported (generally comparable with an age- and gender-matched population [13, 21, 22]. Freedom from reoperation rates have been reported to be greater than 90% at 5 years [22, 23]. Others have reported postoperative symptomatic improvement to NYHA class I or II at follow-up and are experiencing favorable if not more than favorable results preoperatively [13, 21, 22]. Quality of life scores are also reported as equal to or greater than those of the age- and gender-matched population [14, 24, 25]. When interviewed the majority of elderly patients believed that undergoing the operation had been an advantageous idea [13]. These studies warrant a more aggressive approach.

Our study population was highly selective and included only octogenarians exhibiting mitral degenerative disease or bacterial endocarditis who underwent first-time valve surgery. We did not include patients with rheumatic heart disease, concomitant coronary artery disease, or pronounced aortic disease, so that we would only include patients with isolated mitral regurgitation as the primary pathology in a group that exhibited typically repairable mitral valve disease. In this patient population, mitral surgery was safe and reliable and indicated a low incidence of complications and no need for reoperation. The comparison between the life expectancy of the general population of the same age and the survival rate of our patients indicated no significant difference. A marked improvement was observed in the NYHA functional class of our patients at follow-up.

Bioprostheses have traditionally been considered a suitable choice for the elderly, given the higher freedom from structural deterioration evident in older patients and the lack of requirement for long-term anticoagulation [21, 23, 26]. Chordal-sparing techniques for MVR might confer additional advantages by preserving left ventricular performance [12, 27]. Recent data from the Society of Thoracic Surgeons National Cardiac Database demonstrates that the proportion of patients with mitral disease who have their valve repaired rather than replaced decreases with age [28]. In contrast to the established practice valve repair in older patients has been associated with favorable operative survival [12, 21, 29] and shorter hospital stay [29] than valve replacement and indicates comparable long-term outcomes [29]. Our institutional policy was to repair the mitral valve whenever possible and to replace the valve only when adequate repair was not considered feasible. Because of the limited number of patients in our series, the study of association with regard to potential risk factors including operative strategy with adverse events was limited to a univariate analysis. A full comparison between repair and replacement was not possible. The identification of potential risk factors for thromboembolic and hemorrhagic complications could have been affected by a type II error because of the low number of events. However no considerable association between the surgeons' decision to repair or replace the valve and perioperative and long-term outcomes was detected.

Although some reports have emphasized that MVRe need not include annuloplasty rings [30–32], it seems that remodeling annuloplasty, besides reshaping the annulus, allows for a more stable repair regarding degenerative disease [4, 6, 33–35]. Ninety-three percent of our reparative procedures included a posterior annuloplasty.

Recurrence of a substantial degree of regurgitation has been described after mitral repair by many authors [3, 33, 34, 36, 37]. A complete long-term follow-up was performed by Flameng and associates reporting the recurrence of significant regurgitation in 18% and 29% of the patients at 5 and 7 years, respectively, after repair for degenerative mitral disease [6]. Higher rates of recurrence were observed in our population. Echocardiographic follow-up was available for only 50% of the patients. Seventeen percent of the patients receiving echocardiographic follow-up were designated as NYHA functional class III–IV compared with 13% of the patients that did not receive echocardiographic follow-up (p = 1.0). Risk factors for recurrence of mitral valve regurgitation after repair have traditionally been classified as procedure-related (chordal shortening procedures, nonuse of a sliding plasty, failure to add an annuloplasty to posterior leaflet resection, the use of annuloplasty alone, the requirement for additional leaflet sutures to increase local coaptation, residual mitral regurgitation at the completion of repair, performance of concomitant cardiac procedures) and valve-related (rheumatic disease, advanced degenerative changes of both leaflets) [4, 6, 33, 37, 38]. Among our patients with moderate or greater mitral regurgitation at follow-up, 4 underwent a posterior excision with annuloplasty, 2 underwent a simple annuloplasty, 2 underwent complex repairs including chordal shortening, and 1 underwent a replacement with a bioprosthesis. In all of these patients the etiology of the primary mitral valve disease was degenerative. Progression of the degenerative disease and reparative techniques could have played a role in the recurrence of regurgitation, but the limited numbers do not allow significant inferences.

Recent advances with regard to the comprehension of the natural history of mitral valve disease have changed the approach from a relatively passive response to the development of severe symptoms to an early surgery concept preceding the signs of left ventricular dysfunction [19, 33]. Our data suggests that the elderly should not be excluded from this concept because of age alone. Favorable preoperative NYHA class and favorable preoperative left ventricular function has been associated with favorable long-term survival in the elderly population [19, 21, 39]. When the surgical approach preceded the onset of left ventricular dysfunction, an improved freedom from late cardiac death and from the need for subsequent heart-related hospitalization was indicated.

An observed survival rate comparable with the expected survival rate of the general population, the improvement in the functional status of the patient, the low incidence of complications, and the absence of the need for reoperation provides evidence that octogenarians with nonischemic, nonrheumatic mitral regurgitation can achieve beneficial results from mitral valve surgery. Our emphasis on reparative techniques did not result in a survival advantage compared with replacement but did prove to be a reliable approach regarding elderly patients. Surgery performed at an early stage, preceding the development of left ventricular dysfunction, was associated with an improved freedom from late cardiac complications.

	Acknowledgments

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
We thank Judy Lenoch, Julie Koehler, and Beth Moran for their assistance with data collection.

	References

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 

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