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Ann Thorac Surg 2006;82:1391
© 2006 The Society of Thoracic Surgeons
Cardiac Surgery, Massachusetts General Hospital, White 503, 55 Fruit St, Boston, MA 02114
(Email: cakins{at}partners.org).
Advanced patient age and reoperative status have been routinely identified as significant risk factors for mortality and morbidity after cardiac surgical operations. Eitz and colleagues [1] studied a cohort of patients in which these risk factors are emphasized, reoperative aortic valve procedures in octogenarians. The 30-day mortality rate of 16% compared with 7% for first-time aortic valve replacement, and increased rates of postoperative atrial fibrillation, heart block, reexploration, circulatory support, and resuscitation, confirm the significance of advanced age and reoperative status as risk factors.
One might contend that the relatively early need for reoperation in this series may be a reflection of the durability of the primary prosthesis used, the Mitroflow valve, since the principal indication for reoperation was structural dysfunction, almost all of the patients were more than 70 years old when the valve was implanted, and the mean interval between operations was only 8 years. That approach would miss the message of this study, however.
Most cardiac surgeons will be seeing more bioprosthetic failure in octogenarians because of the paradigm shift to increasing bioprosthetic aortic valve replacement worldwide. For example, the STS Database documents that in the United States, aortic bioprosthetic implantation grew from 36% in 1995 to 74% in 2004.
The lessons of this study are important; they will be needed in the future by all cardiac surgeons. Earlier reoperation, careful intraoperative physiologic monitoring, and increased use of mechanical circulatory support, when necessary, should contribute to improved results.
An important observation from this study was that patient survival after either first-time or reoperative aortic valve replacement was significantly less than that for an age-matched and gender-matched cohort from the German population. This finding confirms other studies that documented diminished survival after aortic valve replacement, and suggests that patients who require aortic valve replacement have a disease that predisposes to earlier death, or that valve replacement merely exchanges native valve disease for "prosthetic valve disease," or both. However, the mean late survival of 5.6 years and improved functional results validate the efficacy of the procedure for those who survive.
Reoperation for aortic prosthesis dysfunction should not be denied to octogenarians merely because of their age. Increasing need for these procedures should allow surgeons to better identify those patients who will most benefit from reoperation.
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